Category: Free Essays

This essay will analyse how issues of ‘race’ and culture are pertinent to mental health problems and to service responses to minority communities. However, other risk or causal factors will be considered which are essential in fully understanding diagnosis, access to services and outcomes of mental health issues including poverty, racism and violence against women. It appears that a combination of cultural, structural and individualist factors are linked to mental health issues and it will be highlight why an over focus on ‘race’ and culture (without considering other factors) can be dangerous.

Although individual factors will not be discussed in this essay, their importance must be emphasised. Personal elements intersect with other factors (structural and cultural) contributing to mental health problems. Individual factors on their own therefore are not enough but need to be considered in combination with cultural and structural factors. This can be linked to Thompsons PCS Model which looks at Personal, Cultural and Structural issues in terms of anti oppressive practice (Thompson, 1997).

It cannot be ignored that issues of ‘race’ and culture are extremely relevant when considering mental health. However, this essay views race as “socially constructed, with little biological validity as a risk factor that fully explains inequalities in health” (Bhui et al, 2005, p.496). What is more feasible and supported in studies such as the EMPIRIC study, is that race is a factor which can be a sociological risk to individuals which can be referred to as racial discrimination having the potential to result in lower self esteem, fewer opportunities, and stress leading to mental health problems (Bhui et al, 2005). In the UK racial discrimination does not just refer to the term ‘race’ as skin colour but also incorporates cultural differences as well (Bhui et al, 2005). Therefore in this essay, when ‘race’ is referred to as leading to mental health problems; it will be in terms of the explanation put forward previously.

It appears that ‘race’ and culture impact on diagnosis, access to services and outcomes. However, this view is based on research obtained in a short amount of time – it was only in 1995 that observing different ethnic groups became obligatory in mental health services which are publically funded (Mind, 2012). However this view is disputed by Glove and Evison (2010) who argue that “differences in the pattern of mental health care received by minority ethnic groups in England have been noted since the 1960s and widely debated since the 1980s”. Irrespective of this dispute, both agree that research has identified differences between different ethnic groups in diagnosis, treatment and availability of services. A common identification in literature is that there are high rates of psychosis (for example schizophrenia) amongst African Caribbean men and apparently low rates of mental illness among South Asians (NCSR, 2002). Influential pieces of research identifying these differences include the Count Me In census which began in 2005 and was created in support of the Department of Health’s five year plan ‘Delivering Race and Equality in Mental Health Care’ (Mind, 2012). The ultimate aim was to reduce admission rates, detention and seclusion amongst black and minority ethnic groups (Mind, 2012). The census identifies that 22% of 30,500 individuals receiving in-patient care were from minority ethnic groups (CQC, 2010). It also highlights that black men are more likely to be detained under the Mental Health Act and that black and black/white mixed race men are three times more likely to be admitted to psychiatric wards and had the highest admission rate of all groups (Mind, 2012). CRITICISM The Fourth National Survey (FNS) of ethnic minorities supports this to an extent. It identifies higher rates of psychosis diagnosis amongst Black Caribbean’s compared to white people (Mind, 2012). However, these differences are lower than previous studies have suggested. Studies undertaken previously have suggested psychosis occurs mostly amongst black Caribbean men however this study suggests higher rates amongst black Caribbean women (Mind, 2012).

Despite these figures, findings have also suggested that Black African Caribbean and South Asian patients are less likely to have their mental health problems detected by a GP (The centre for Social Justice, 2011). Black men have been found to be more likely to be admitted to psychiatric units via the Criminal Justice System (CJS) (NMHDU, 2010). The Count Me in census highlighted that Black Caribbean, Black African and White/Black Caribbean mixed groups are between 40 and 60 per cent more likely to be admitted via the CJS (CQC, 2010). In contrast to this, findings from the census identify that admission rates among South Asian and Chinese groups have remained much lower (below average in many cases) (Care Quality Commission, 2011). This is interesting, as other research has indicated that some specific subgroups of South Asian women (ages 15-24) are at high risk of completed suicide (Raleigh, 1996). Therefore, why are they not getting the necessary support from mental health services?

The EMPIRIC study considers white people as a comparison with Bangladesh, Black Caribbean, Irish, Indian and Pakistani groups (Bhui et al, 2005). This study was undertaken in the community which is quite rare. It considers the impact of racial discrimination in the workplace (Bhui et al, 2005). The study identified that Black Caribbean people reported the highest amount of job denial and Pakistanis the highest level of insult (Bhui et al, 2005). Bangladeshi, White and Irish people were found to be less likely to report discrimination (Bhui et al, 2005). Discrimination in the workplace is common and is a risk factor for common mental disorders (Bhui et al, 2005). The differences between each group in terms of Common Mental Disorders (CMD) were small and there were some variations in terms of age and sex (Bhui et al, 2005). It found CMD were higher amongst Pakistani and Irish men ages 35-54 and higher rates amongst Indian and Pakistani women ages 55-74 (Weich et al, 2004). Common Mental Disorders were found to be lower in Bangladeshi women than white women which is interesting considering this group has the highest level of socio economic deprivation and the accepted link between poverty and mental health (Weich et al, 2004). There were no differences in rates between Black Caribbean and White people despite them suffering the most job denial and this identifies differences to findings from other key studies which often identify higher rates of mental illness amongst black men in particular (Weich et al, 2004). Therefore this suggests this group may be more resilient or Black Caribbean people with CMD may have been excluded from jobs (Bhui et al, 2005). The EMPIRIC study actually identifies that Black Caribbean women had more CMD than Black Caribbean men (Bhui et al, 2005) and as findings from FNS also suggest an area of concern for this group, it appears further research should be undertaken. There are some criticisms on this study being that what is perceived as racism does not always impact on current employment experiences (Bhui et al, 2005). It does not consider the fact that CMD may result in more people reporting racial discrimination (Bhui, 2005). More long term and qualitative studies may be beneficial in understanding the impact of racial discrimination (Bhui et al, 2005). However, studies undertaken late 1990s and early 2000 because there was a raise in concern regarding this issue (partially due tot the Rocky Bennett case) therefore the government commissioned this research due to these concerns. However, in recent years things have died down a bit therefore less research is being undertaken so knowledge is not developing and there is no funding available for researchers.

Despite this, research already carried out seems to follow suite in identifying differences in the diagnosis, treatment and outcomes of mental health for ethnic groups, however these differences are not always on par with each other and identify differences in themselves as already stated (McLean et al, 2003). It is important to understand why variations do exist between ethnic groups in terms of mental health which will be the focus of the rest of this essay.

It cannot be ignored that cultural factors undoubtedly play a role in the findings identified previously. Black and minority ethnic (BME) groups may speak in a way which is considered ‘different’ to white British individuals or they may have dissimilar mannerisms. As a result, this may be interpreted wrongly which could subsequently lead to an incorrect diagnosis of mental health issues (Singh, 2006). As stated “western psychiatrists are more likely to misinterpret behaviour and distress that is alien to them as psychosis” (Singh, 2006). Individuals may be labelled as “strange” or “unusual” because of cultural traits (Singh, 2006). Thus, this identifies that a lack of understanding of cultural differences may impact on interpretations. However, no matter what cultural training people obtain, interpretations of behaviour are always going to vary as cultures are complex and continuously adapting.

Another argument relating to ‘race’ and culture and its link with mental health is that some cultural groups may not react to western-type methods of dealing with mental illness. For example, in Western society, psychiatry is viewed as an objective discipline and therefore the individual receiving the support/therapy is separated from the therapist (Fernando, 2004). It is likely that the therapist will not know the individual and will rarely have any physical contact with them. As put forward “the therapist learns the treatment and applies it within the overall medical model of dealing with problems as individual illnesses, disorders or disturbances of what is assumed to be ‘normal’ mental functioning” (Fernando, 2004, p.121). This way of approaching mental health may be different to other cultures for example where more spiritual methods of healing may be used (Fernando, 2004). As a result, certain ethnic groups may not involve themselves in western methods for example going to see a General Practitioner (GP). Koffman et al (1997) found that in comparison to non-black groups, more black patients who had been admitted were not registered with a doctor. This may be a result of different cultural methods of healing in which western practices do not fit. However, culture should not be considered as stationary or immobile – it does and can adapt and change. It is important to recognise that different cultures can begin to interlink with each other as cultures may react to the environment they are in contact with (MDAA, 2012). This identifies how it can be dangerous to focus too much on culture which I will look into further on in the essay.

Language is a cultural factor which can impact on the right diagnosis and support for an individual: “both diagnosis and treatment are handicapped if there is no common language between doctor and patient” (Farooq and Fear, 2003, p.104). Even when an interpreter is involved, they may not be trained in psychiatry which can limit understanding and can have a negative impact on translation (Farooq and Fear, 2003). However, I would argue that at least if an interpreter is involved, they can bridge the language barrier to a significant extent. As argued “patients in mental health services will experience a better quality of care when accessing interpreters” (Costa, 2011). This is emphasised in the NICE Guidelines for GA, Schizophrenia, Depression and Dementia which puts forward that written material should be translated into different languages and interpreters should be used where appropriate (ref). A mental health professional that comes across a patient of a different culture, who speaks a different language, may not recognise the severity of their symptoms due to the cultural and language differences resulting in lack of support from services for example. Therefore if someone presents to their GP with symptoms these may be misinterpreted if an appropriate interpreter is not present. Therefore although many mental health settings may use interpreters regularly, others may not and the importance of this must be emphasised in order to work through issues of wrong diagnosis, treatment and outcomes of mental health.

Although ‘race’ and culture are evidently pertinent to mental health problems and service responses, it is necessary to consider other factors as “an emphasis on cultural issues can sanitize or mask other issues” (Chantler et al, 2002, p.649). It seems that mental health services are focusing on cultural differences and understanding cultural diversity in an attempt to overcome the differences in diagnosis and support for different ethnic groups. However, in their attempt to do this they may actually be ignoring other key issues thus potentially making the situation worse or at least maintaining it. Some argue that “there is an urgent need to develop cultural competence among nurses and other care workers if they are to meet the needs of the diverse populations they serve” (Papadopoulos, L and Tilki M and Lees S). However, professionals may not treat black people any differently just because they are trained to be culturally aware (Fernando, 2004). There are lots of references to cultural competence in the Department of Health and NHS. The government strategy No Health Without Mental Health which replaced New Horizons in 2011 seems to focus on culture but does not seem to acknowledge important links between race and mental health.

It is well known that there is a significant link between poverty and mental health (Chantler, 2011). It appears that mental health social work is beginning to revolve around the bio medical model therefore social factors such as poverty are not focused on as much as they should (Chantler, 2011). It has been identified that social exclusion can often be a result of poverty as a lack of financial means results in the poorer sectors of society being unable to involve themselves in societal activities thus resulting in exclusion (Gilchrist and Kyprianou, 2011). Social exclusion/isolation can impact on mental health therefore poverty can be viewed as a risk factor for mental health problems (Chantler, 2011). Being in the lowest social class is often linked with poverty and this is something which spans across different ethnicities and cultures. Therefore white, working class members of society may experience mental health issues which are instigated as a result of poverty thus race and culture cannot be viewed as the only factors impacting on mental health – other factors which can also impact on white sectors must be recognised.

However, black and minority ethnic groups may find it more difficult to move into higher classes as a result of issues such as racism and discrimination thus may remain in low socioeconomic circumstances. This highlights a link between poverty and ethnicity and emphasises the concern that peoples race and culture may result in them being forced into situations which could increase their likelihood of mental distress. It appears that there are two main ways racism can impact on individual’s health: the immediate psychological and physical impact and the result of which different races and cultures are not valued within society resulting in social exclusion and disadvantage (Karlsen and Nazroo, 2000). As argued “racism, whether openly hostile or lurking in institutional cultures and practices, limits the opportunities and life choices individuals make” (Gilchrist and Kyprianou, 2011, p.7). Therefore, certain people of certain races or cultures may feel more comfortable remaining in communities together due to racist discrimination or prejudice and as a result may not seek new life opportunities thus potentially remaining in poor socioeconomic circumstances as a result of this forced exclusion (Gilchrist and Kyprianou, 2011). Similarly, discrimination and racism may result in less support within education arenas and less opportunities to excel within employment circles (Gilchrist and Kyprianou, 2011). It has been recognised that unemployment has an impact on mental health (Meltzer et al, 1995). Findings from the Fourth National Survey identify that four fifths of Pakistani and Bangladesh respondents, two-fifths of Indian and Caribbean respondents and one third of Chinese had incomes lower than half the decided national average – recognised as poverty (Karlsen and Nazroo, 2000). This compares to one in four white respondents. Thus, this may be the impact of racism, discrimination and disadvantage (Karlsen and Nazroo, 2000) Therefore there seems to be a vicious cycle whereby BME groups feel the impact of structural oppressions resulting in fewer opportunities to break away from factors which can lead to an increased risk of mental health problems, such as poverty. Therefore, arguably social exclusion, poverty and class could be reasons why there are higher levels of mental illness in some subcultures of South Asian women for example (Karlsen and Nazroo, 2000). The fact that communities ‘stick’ together may result in further antagonism and segregation thus resulting in inappropriate support for mental health problems as ‘outsiders’ may not want to intrude in these cultures – they may take the attitude ‘leave them to it’ which can be very dangerous. Therefore a combination of factors including class and poverty can emphasise mental health issues.

It seems that the role of racism as a risk factor for mental health is being ignored or at least undermined by the coalition government. Although the No Health Without Mental Health strategy acknowledges the need to consider causal factors for mental health, it appears to neglect to discuss the pertinent issue of racism/institutional racism which can be viewed as a downfall in response (Watson, 2011). Therefore, it neglects significant links between race and mental health. This is emphasised in its ‘a call to action’ document, which does not include any BME organisations (Vernon, 2011).

Stereotyping of different groups refers to the discrimination of groups based on views they are certain way. So, South Asian groups may be viewed as having lots of family support and not believing in mental illness. This can be dangerous as it may result in services neglecting to offer support to certain races or cultures. Therefore, it appears that some mental health professionals may inherit views regarding racial stereotypes (Fernando, 2004). Another common racist stereotype is that black men are dangerous which again impacts on diagnosis and treatment. A well known example is that of Rocky Bennett. He was killed in 2004 in a medium secure psychiatric unit after being restrained by up to five nurses and an independent inquiry into this accepted that it was a result of institutional racism (Athwal, 2004). This is not a lone incident and has been recognised as an issue across mental health services. A concern which is shared by many including Richard Stone (a member of the Bennett inquriy panel) and Errol Francis (a campaigner on black mental health) is that cultural/racial awareness training will not reduce institutional abuse, it must be acknowledged and then the behaviour of the professionals and workers needs to change (Athwal, 2004). Once understood and acknowledged, progress can be made to tackle and understand causes (McKenzie, 2007). McKenzie (2007) put forward concern that the importance of Delivering Race Equality would be undermined, which seems to have been the case in No Health without Mental Health as it does not seem to recognise the importance of racism as a risk factor for mental health and the impact it has on service responses (Watson, 2011). Watson (2011) argues that “the impression given is that we are moving to a post-racial big society where ‘state multiculturalism’ is expunged from British values and public consciousness…” Thus the link is being undermined and if this is the case it is unlikely changes will be made.

Chantler et al (2002) undertook a ten month qualitative study with a group of South Asian women who are survivors of self harm or attempted suicide. It seems that survivor’s highlighted issues causing mental distress including immigration status, poverty, and domestic violence in their accounts however an over focus on cultural sensitivity by professionals and policy makers means that these factors often goes unrecognised (Chantler et al, 2002). Also, important to note is that there does not seem to be much research into the fact that if people are seeking asylum, there is a possibility that their mental health needs may be higher as a result of their experiences prior to migration (Chantler, 2011). As a result of lack of recognition, inappropriate or a lack of support was offered by services. The researchers found that the survivors who had been seeking asylum mentioned policies such as the ‘one year rule’ as causing them distress and oppression as it meant they were trapped (often in an abusive relationship) for a long period of time without a chance of escape (Chantler et al, 2001). As stated, “current immigration legislation strips South Asian women of the legal and personal support available to white British female citizens” (Chantler et al, 2002). The survivors identified that they felt these policies ensured that all power was given to the man (Chantler et al, 2002). Policies implemented trying to overcome problems in services by employing South Asian workers needs to be looked into (Chantler et al, 2002). It seems that policy makers used cultural clashes as explanations as to why issues such as domestic violence, immigration issues and poverty were not highlighted (Chantler et al, 2002). Thus in models of mental health, factors such as immigration are neglected. Services claimed to be unable to meet their needs due to cultural conflict (Chantler et al, 2002).

All but one of the survivors in the study had suffered domestic violence identifying the link between domestic violence, immigration status and suicide/self harm (Chantler, 2001). It is worth noting that refugees and asylum seekers may have experienced traumatic events before arriving in the UK such as war and poverty therefore they may have higher mental health needs because of their experiences – this is not covered much in research and is something which may be beneficial in our understanding.

Burman et al (2005) focuses primarily on domestic violence services with regards to African, African-Caribbean, South Asian, Jewish and Irish women, it became evident that culture was seen to be more important than dealing with domestic violence issues. Thus a focus on culture can be seen as an obstruction to offering the appropriate support (Burman, 2005). The study also identifies how other issues such as immigration policies prevent asylum seeking women from being able to leave abusive relationships therefore this needs to considered more (Burman, 2005). “racialised dimensions of such policies heightens their exclusionary effects”. The outcome of these findings suggests that there needs to be new ways of supporting women from minoritised groups suffering domestic violence (Burman, 2005). Criticisms of study?

It seems that in favour of culture, gender issues such as violence against women are often ignored in relation to minority ethnicities (Chantler, 2002). Would this be the case if it were white women? What is interesting is that violence against women is considered a gender issue in relation to white women but is seen as a cultural issue in relation to South Asian women (Chantler et al, 2002). This is something which needs to be recognised and changed. Cultural factors need to be acknowledged to a degree and particularly in certain circumstances for example honour based violence, however it needs to be recognised that culture and race are not always at the forefront of issues. It is important to move away from a complete focus culture in many instances, and consider gender issues as well. Segregating women from minority groups from white women with regards to violence can lead to lack of support thus potentially resulting in self harm/attempted suicide amongst other issues, as a result of the mental distress. The research undertaken by Chantler et al (2001) and Burman (2005) highlight this.

Conclusion:

As a social worker it is important to recognise cultural differences and be open about culture so that interventions are not so difficult however, although being culturally aware is useful, it is impossible to recognise all factors as cultural as there are numerous different cultures which are constantly adapting. Also, as this essay has identified, an over focus on culture can be dangerous. It is important to be conscious of other risk/causal factors of mental health such as violence against women, class and immigration status. It is essential label or stereotype someone based on their race or culture but rather engage, empower and empathise with service users. As Chantlers’ 2001 study identified, regardless of a service users race or culture, they often just want someone to listen to them. Do not always presume it is about culture as policy has tended to do in recent years. It seems that a combination of structural, cultural and individual factors including gender, poverty and culture will enable a greater understanding of diagnosis, treatment and outcomes of mental health. Considering one without the other will limit understanding. Therefore, knowledge needs to be more nuanced. I am not undermining the importance of race and culture in relation to mental health and service responses, as I have acknowledged its importance in this essay. However, do not neglect other equally important factors.

Also gender issues need to be considered for example domestic violence. Why is domestic violence considered cultural only when related to certain ethnicities e.g south Asian women??

SOME violence crimes are specific to certain cultures for example honour based violence, trafficking (UMHDU, 2010)

However, all ethnicities within the uk experience gender based violence not just certain ethnic groups and evidence suggests that violence and abuse cause mental health issues (UMHDU, 2010). However it is sometimes only seen as a gender issue when it is white women suffering abuse. Seen as a cultural issue when minority ethnic group.

Maybe it isn’t a cultural issue but a gender issue??

Research by Chantler et al – many women from different ethnicities don’t mention culture/race in their study – just mention abuse therefore maybe just need to consider this???

Outline the key areas of knowledge, skills and values required to carry out an effective and anti-oppressive social work assessment. Illustrate your answer from ‘one’ of the following areas of professional practice: Mental Health

The key areas of knowledge, skills and values which are required to carry out an effective and anti-oppressive social work assessment within the are mental heath have been set out within the various theories of social work assessment and involve engagement, effective communication skills, good inter-personal skills, non judgemental viewpoints, planning skills, confidence, experience, knowledge of the service user’s case history and an informed approach to assessment of users (Williams, (2002) 1) (Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (2006) 14). This list is by no means exhaustive and it certainly is the case that there are some skills which merely require common sense and a pragmatic approach to the practice of social work assessment (Cree, V. (2003) 40) (Payne, M. and Shardlow, S. (2001) Ch. 1). From the writer’s perspective, specifically within the area of mental health, these skills arguably need to be more attuned in the social worker who wishes to carry out effective and anti-oppressive social work assessment. The social worker within the area of mental health will also require a firm knowledge base of the ways in which mental illness may manifest itself, and therefore the social worker will be able to identify the symptoms of common mental illnesses such as depression, bi-polar disorder, schizophrenia and others more readily and accurately. In this sense a combination of a good knowledge of the theory and practice of mental health social work will be essential tools for the social worker who wishes to be able to carry out effective and anti-oppressive social work assessment.

An effective and anti-oppressive social work assessment in the area of mental heath is a complex process which requires an understanding of the complex socio-legal environment that the social worker often operates within (Beckett and Maynard (2005) 46). This means that the social worker will need to be familiar with the various regulatory and legal frameworks within which they must operate (Higham (2006) Ch 1) (Beckett, C. (2006) Ch. 1) (Davies, M. (2000) 1-20). The social work care ethos is also increasingly making the role of the social worker more onerous and this viewpoint is supported by the presence of more prescriptive practice guidance in the area (Beckett, C. (2006) 4) (General Social Care Council (2006) 1). The Department of Health has issued specific policy guidance in the area and in particular the policy guidance which is of relevance here is that which relates to vulnerable adults and the mentally ill. The General Social Care Council, which was set up in 2001^[1], has issued guidance and codes of conduct for social workers outlining these frameworks and the context in which they should be adhered to, and this is particularly highlighted by the General Social Care Council themselves through their website (http://www.gscc.org.uk). Other bodies such as the Social Care Institute for Excellence have conducted sociological research which has shaped these contexts and frameworks. Within the sphere of mental health care assessment, the Social Institute for Excellence has issued guidance on how the needs of mentally ill older people should be assessed and they have given the following advice about mental health care assessment: ‘Everyone has mental health needs, though only some people are diagnosed as having a mental illness….older people are more likely to experience events that affect emotional well-being, such as bereavement or disability….Health and social care professionals should carry out an assessment of the needs of…people they are working with, which means talking…about…health and any illnesses or disabilities…finding out…any problems…. (www.scie.org.uk)’.

This above mentioned guidance has made the position of social worker more complicated. This rationale particularly applies to the area of mental health, because the skills needed to deal effectively in this area require an ability to relate to people across a whole spectrum of ages. In this sense, anti-oppressive and effective social work assessment is key. However, what are the ingredients of an effective and anti-oppressive social work assessment? Perhaps this is a question which invites an extremely broad response, which is open to subjective interpretation. Nevertheless, it is possible to argue that planning and effective assessment are two of the most important competencies when it comes to social work assessment. This is the case, perhaps primarily because the law requires the social worker to be aware of the legal duties which they owe to mentally ill and other patients (General Social Care Council (2006) 1).

However, the assessment of mentally ill patients is often associated with a minefield of difficulties. One piece of legislation which is relevant in this regard is the Mental Health Act 1983 which is often instrumental to social workers in their efforts to deliver appropriate care within the area of mental health. However, this piece of legislation places legal responsibilities upon social workers as well as other social care professionals who deliver frontline services to mentally ill people. It is a controversial piece of legislation and it is also regularly invoked by professionals within the field of social care. This makes the responsibilities which are owed by social workers to their service users even more crucial, and it makes good values such as understanding, non-judgemental behaviour and views and honesty even more important within the sector of social work assessments.

It is the case that many controversial issues come to light when the Mental Health Act is invoked in the interests of a mentally ill user who lacks the mental capacity to care for themselves. Firstly, there is the issue of deprivation of liberty by virtue of the Mental Health Act, and a social worker will often be asked for their opinion in the execution of the provisions of the Mental Heath Act, or they will be required to support service providers such as doctors who may not know a patient as well as the social worker does. This legislation allows for a mentally ill person to be ‘sectioned’ and brought to an institution against their will in order to receive treatment for mental health problems. In this particular regard, the principles of effective and anti-oppressive social work assessment are very important, not least because the input of social workers will often be considered key where a doctor or other senior health care professionals will be required to invoke powers under the Mental Health legislation.

A mentally ill person often may not appreciate what care is best for them, and interventions are often necessary to deliver the care that is required. However, this power of intervention can be abused, misused and conversely it may negligently not be invoked when it should have been. This is where effective communication and interpersonal skills are pivotal to the social worker who wishes to carry out an effective assessment. The powers which may be affected under the Mental Health Act require the support of two of more health care professionals, one of whom must usually be a doctor. This means that the social work must be capable of communicating their opinions on the most sensible intervention, the service user’s history and background, to the various actors who will be involved in the process whereby the need of a mentally ill person will be assessed (Scottish Executive (2006) Section 1.3) (Hill, M. (1991) Ch. I) (Philpot, T. (1998) 1-10). Communicating their opinions may not always be a direct process, which is why social workers are often required by law to keep adequate records and case histories of their contact with vulnerable people in their capacity as social workers, so that information can be communicated to other professional actors who need to rely upon it through record keeping.

On another level and in terms of communication and interpersonal skills, the social worker must also be able to communicate with the service user themselves. This is particularly difficult for the social worker, as they will often be the first individual who will be informed that a mentally ill service user is perhaps in need of the intervention of social care providers. In this context, and from the personal point of view of the writer, planning the interaction between social worker and service user through reading the background and case history of the person involved, if this information is available will be pivotal. This process is all the more difficult as the service user may lack any communication, and or inter personal skills. Mental illness is often a very absorbing process, and the service user may also be frightened or delusional, and consequently not capable of effective or any communication. Therefore the social worker’s communication and inter personal skills are often tested immeasurably within the context of a mental health care assessment, and are crucial tools if assessment is to be carried out effectively and anti-oppressively.

The interpersonal and communication skills which are needed must also be non judgemental, and this is very important if an anti oppressive assessment is to be carried out. The social worker must be prepared to distance themselves personally from the situation, and not to take any unwarranted criticism from the service user with mental health too personally. The person will inevitably feel very threatened by interventions from outside agencies and actors, and this will often lead to an angry reaction from the service user involved. It must also be remembered that communication between social worker and user may not always be through language, and therefore a calm outlook on life, as well as confidence and experience are also key factors which must be considered by the social worker who wishes to carry out appropriate assessments. These factors will often be picked up on, even sub consciously by the mentally ill service user, who may feel more threatened if they feel that the person who approaches them to assess their needs is not entirely confident of their own abilities.

In conclusion therefore, there are many skills which are critical when the needs of a mentally ill person are to be assessed and these may often be described in terms of knowledge, skills and values. This essay has argued that out of all the competencies that a social worker must have, communication skills, interpersonal skills, record-keeping and planning are arguably the most important. Sound values and skills such as administrative and managerial skills are also pivotal, but this essay has argued that without good communication skills, in particular a social worker’s ability to carry out effective and anti-oppressive assessments will be compromised.

Bibliography
Books

Beckett, C. and Maynard, A. (2005) Values and Ethics in Social Work. Publisher: Sage Publications. Place of Publication: UK.

Beckett, C. (2006) Essential Theory for Social Work Practice. Publisher: Sage Publications. Place of Publications: UK.

Cree, V. (2003) Becoming a Social Worker. Publisher: Routledge. Place of Publication: UK.

Davies, M. (2000) The Blackwell Encloyopedia of Social Work. Publisher: Blackwell. Place of Publication: Oxford, UK.

Higham, P. (2006) Social Work: Introducing Professional Practice. Publisher: Sage Publication. Place of Publication: London, UK.

Hill, M. (1991) Social Work and the European Community: Social Policy and Practice Contexts. Publisher: Kingsley Publishers. Place of Publication: UK.

Payne, M. and Shardlow, S. (2001) Social Work in the British Isles. Publisher: Kingsley Publishers. Place of Publication: UK.

Philpot, T. (1998) Caring and Coping: Guide to Social Services. Publisher. Routledge. Place of Publication: UK.

Articles

Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (2006) Strategy for Social Work and Social Care. Publisher: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust. Place of Publication: UK.

General Social Care Council (2006) GSCC Welcomes Healthcare Professional Regulation Reviews. Publisher: General Social Care Council. Place of Publication: UK.

General Social Care Council (2006). Social Worker Cautioned Following Hearing in London. Publisher: General Social Care Council. Place of Publication: UK.

Scottish Executive (2006) The Need for Social Work Intervention. Publisher: Scottish Executive. Place of Publication: UK.

Williams, C. (2002) A Rationale for an Anti-Racist Entry Point to Anti-Oppressive Social Work in Mental Health Services Critical Social Work, 2002 Vol. 3, 1.

Websites

http://www.scie.org.uk/news/mediareleases/2006/200406.asp

http://www.gscc.org.uk/Good+practice+and+conduct/

Knowledge based practice

Introduction

This paper will look at how research informs practice. I will be looking at young people and substance misuse and older people and how research might inform or affect my practice.

Good professional practice is knowledge based practice which often means that it is practice based on what others have done, or research that others have undertaken. Research is an important part of most aspects of the human services. In health, in education, and in social work research is important informs our view of the world and can provide a framework for dealing with a particular subject or case. Research has a prominent place in the social services and it is important to the social worker. When people undertake research into areas of social and health care, then these findings and recommendations are generally used to inform practice.

Not only is research important in informing social work practice, it is also important when it comes to Government policy. Like most social workers I have found some research an invaluable asset when dealing with disaffected and vulnerable groups such as young children and socially excluded young people.

Some research may have been undertaken some time in the past but its findings still prove to be useful today. Willis’ (1977 in Giddens 2001) used group interviews (what are sometimes called focus group interviews) in his study of working class boyS and the ways in which the education system attempts to prepares them for the labour market. Both individual and group interviews were used in collecting this data, and while the work has been criticised it provided, and continues to provide useful information about how working class boys communicate and interact. This type of research is a source of invaluable knowledge to someone working with young people. It provides some insights into why youngsters react against authority and why they might act the way they do. Research can be a two edged sword, on the one hand it informs, and on the other it can produce lasting impressions that can lead to oppressive policy making. While Government papers on young people set a framework for social workers, this kind of early research is useful when dealing with them in a practice context. Yet another valuable, yet some might say, problematic, source of information is Bowlby’s (1946) work on why young people commit crime or get involved in substance abuse.

While Bowlby’s work, (which points to maternal deprivation as a cause of problematic behaviour in young people )has been deeply criticised within academic circles his ideas still have a significant impact on current Government discourses on youth. Certainly many social workers find themselves dealing with youngsters who have substance abuse problems and may feel themselves in an ethical dilemma when confronted with some of the policies in this area. One of the worst influences that work such as this has had is the growing tendency to treat anyone who does not conform to society’s norms as sick and deviant. Government initiatives on drugs, more often than not, appear to be targeted at poor and working class communities. Further there is a tendency for these initiatives to link poverty and drugs in the minds of other people. If an adolescent comes from the poorer part of town and is perhaps unemployed then this can lead to people in authority thinking that he/she is more likely to be seen as a drugs user even if they are not. Eley (2002) maintains that this leads to the association of drugs and crime with those who are already underprivileged in society. For social workers this is can be an extremely problematic situation. Do I as a social worker automatically assume something about a young person who is in trouble, and label them as sick and deviant, or do I adhere to what I believe to be the case, that everyone is of equal worth and therefore deserves an equal chance. If I am to abide, in my professional capacity by the 1998 Human Rights Act, then ethically, I could be duty bound to ignore Government guidelines in this area.

Moore (1996) says that Government overstates the case on drug misuse when it refers to drug users as addicts because, he argues, most of the drug use that takes place in Britain is recreational This implies that those who use them are in control of the situation with regard to when they take drugs e.g. weekends, and how much they spend. Theorists are divided on why adolescents take drugs therefore it might be argued that the reason adolescents use drugs are quite complex and differ from person to person. This means that a social worker should act in accordance with the Human Rights Act when dealing with the problems of young people because that also implies treating each case on its individual merits

Becker (1963) has argued that young people are often viewed as delinquent because of the way society viewed certain acts, such as drug taking. Calling or labelling a young person as deviant is problematic because it can become a self-fulfilling prophecy. Those in authority often take the view that young people, and particularly underprivileged young people are deviant and if the label is applied often enough, and by those with the power to apply it, then that is how the adolescent may come to view themselves. Taylor, Walton and Young (1973) however, say that no theory is sufficient unless there is also an analysis of the power relationships that exist in society. Hall (1978) maintains that the way in which adolescents are represented in the media has a huge effect on the way in which they are viewed by others. This can then have a further effect on their actions.

In my own professional practice I have to be aware of such theories and how they inform public perception and Government policy. I also have to be aware of them in my practice and this might involve questioning the assumptions and methods behind certain research findings i.e. I am questioning their theories. Theories aid us in making sense of the world, one explanation of theory is an observation of observed regularities for example that women do more housework than men. Many things are not self-evident but need an explanation, thus Abbott and Wallace (1997) maintain that all of us are theorists because of the need to analyse and interpret our ordinary everyday experiences in order to make sense of them

In sociological theory, some theories are extremely abstract, for example critical theory. Merton (1967 in Giddens, 2001) has called these theories ‘grand theories’ because they operate at a general and abstract level, theories such as those of Willis and Bowlby are middle range theory, because they are looking at an aspect of social life. Usually Merton (1967in Giddens 2001) maintains it is the middle range theories that are more likely to guide research. Labelling theory and Becker’s work, for example is a middle range approach to research that was developed out of the sociology of deviance. The problem is that while I as a social worker dealing with a young person with substance abuse issues might prefer to treat that person as an individual, and ethically I am bound to do so, Government discourses take a quite different view. Drug abuse and crime as mentioned earlier are closely associated in public discourses with poverty and this is evident in recent policy making. When evaluating research and research findings social workers need to find some sort of framework within which to evaluate the work this might be the 12 step approach advocated by Locke or it might be something as simple as using a content analysis approach to evaluate what the researcher has done and decide how effective that research may be.

The Government’s report, No More Excuses (The Causes of Youth Crime) states that deprivation and poverty are usually a contributing factor in youth crime.^[1] Government research suggests that while young people who offend may not do it very often, there are a few persistent offenders who are responsible for the greater part of youth crime new Youth Justice reforms will concentrate on preventing crime and on early intervention where children and young people are at risk of becoming involved in crime.^[2] Leitner et al (1993) maintain that the British public is concerned about drug use, drug dealing, and the crime that is associated with this. Pudney (2003) maintains that if young people take soft drugs such as cannabis then they are more likely to progress to hard drugs and to criminal activity. He also argues that such behaviour is strongly associated with unobservable personal characteristics and New Labour have consistently targeted drugs initiatives at underprivileged communities.

Working with young people means that I have to take into account Government reports as well as other research findings. At the same time I, like many other social workers, have as Moore (2002) points out, entered social work because of a commitment to social justice, or at the very least a desire to help others and to see improvement and positive change in people’s lives. Some critics maintain that the way in which social services often operates is self-serving rather than serving the needs of the clients, yet social workers do police themselves and their profession. The way in which they do this is to think critically about what they are doing, why they are doing it, and what moral implications this may have. Certainly social work ethics should not lead anyone to believe that the social work profession should serve itself, rather the needs of the client should be most important. One of the ways this is achieved is by establishing clear relationship boundaries early on and this is vital when working with young people who have issues around substance misuse. The BASW has to say about social work ethics and values.

The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work (BASW,2001). ^[3]

Social work practice, in order to be ethical practice must be centred on the needs of service users Social workers of necessity intervene in people’s lives and have an influence on situations, ethical decision making is therefore a vital component of social work practice (Osmo and Landau, 2001).

Yet another area where social work practice can be a minefield is in working with older people. When working with older people a social worker has a duty to abide by the 1990 NHS and community care act. Working with older people can be difficult on the one hand there is what you want to achieve as a social worker and on the other there are guidelines that may prevent you from doing your best for a client. There are an increasing number of legal and policy requirements that the social worker dealing with an older person must adhere to. It is difficult for the social worker to negotiate the needs and wishes of the client while remaining within the legislative framework. Working together is not always straightforward. The more recent Health and Social Care Bill of 2001 gives Government powers to require health bodies and local authorities whose services are failing to pool their resources. Parrott (2002) undertook research into the care management process and how it affects social workers and service users. He points out that there is often no common guidelines on which services should be provided, or the standard of care to expect. The social worker may find that he/she has to perform most of the assessment and to discover whether an older person’s family would be prepared to help so that he/she could remain in their own home. Whatever the decision the social worker would also need to ensure that the client could, at some level, participate in the decision making process. Thus the process is fraught with problems, for example a social worker might assess a person as needing a certain level of care but this has to be agreed with the social worker’s supervisor and with care management. So the person may not receive the care that the social worker deems appropriate. Thus the social worker has a dilemma. While knowledge does inform practice it is not the only thing that the social worker has to deal with, management decisions also affect the process as Parrott’s research shows. One thing that has become apparent to me is while research can inform practice, it should not be allowed to determine it, if and when it does this can result in oppressive practice and a complete disregard of the rights of the service user and this is against ethical practice as outlined by the BASW.

Conclusion

This paper has looked at knowledge based practice and how research informs what a social worker does. When dealing with research one is not looking at it in isolation but also having to deal with policies that emerge as a result of that research. Many of the funding restrictions that social workers have to deal with are a result of the 1988 Griffiths report which found that getting organizations to work together, and using a market based approach to social care would save the Government money.

Bibliography

Abbott and Wallace (1997) An Introduction to Sociology: Feminist Perspectives, London, Routledge

Becker, H.S. 1963. Outsiders. New York, Free Press.

Bennet, T. Holloway, K. and Williams T. 2001.Drug use and offending: Summary results of the first year of the New-ADAM research programme. Home Office Research Study 236 Home Office London

Blaxter, L, Hughes, C and Tight, M (1996) How to research. OU press

Bowlby, J. 1946. Forty-four Juvenile Thieves. London, Tindall and Cox.

British Association of Social Workers (2002) The Code of Ethics for Social Work.http://www.basw.co.uk/.

Bryman, A 2004 Social Research Methods 2^nd ed. Oxford, Oxford University Press

Eley, S. 2002. “Community-backed drug initiatives in the UK: a review and commentary on evaluations.” Health & Social Care in the Community10(2),99-105.

Giddens, 2001 4^th ed. Sociology Cambridge, Polity

Hall,S. Critcher, C. Jefferson,T. Clarke, J. and Roberts, B. 1979 Policing the Crisis. Mugging,

Leitner M., Shapland J. & Wiles P. 1993. Drug Usage and Drugs Prevention: The Views and Habits of the General Public. HMSO, London.

Moore, S. 2002 3^rd Edition Social Welfare Alive Cheltenham, Nelson Thornes

Moore, S.1996 Investigating Crime and Deviance London, Collins Educational

Parrott, L 2002 Social Work and Social Care London, Routledge.

Taylor Walton and Young. 1973. The New Criminology. London, Routledge

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Topic: Not everyone is suitable to do crisis intervention work as it is very demanding for the helper. Do you agree? Support your answers with relevant research.

Theoretically speaking almost anyone can be a crisis worker by reading books and practicing the skills but to make interventions effective it is not enough. James and Gilliland (2008, p. 21) stated that almost anyone can be taught the techniques of crisis intervention in a book and apply these techniques to some degree of skills, however it takes more than reading up techniques through a book and mastering the skills to make intervention effective.

Crisis has different meanings to different people; a person may feel deeply affected by an event, while another suffers little or nothing at all, for example, in a conservative society, when a teenage girl discovers that she is pregnant, it is a crisis, but a married woman who is not able to have children is another kind of crisis. As each individual reacts differently, crisis workers need to understand what crisis means to the individual from their point of view as it is crucial in crisis intervention (Coulshed & Orme, 2012).

James and Gilliland (2008, p. 3) define crises as events or problems which are intolerable difficulty that goes beyond the limit of an individual’s resources and coping mechanisms. An individual is in crisis when their important life goals are obstructed by difficulties that they could not resolve within their available resources. It refers not only to an individual traumatic situation or event, but also the individual reaction to an event.

According to Aguilera (1998) in a 1959 address John F. Kennedy stated, “When the word crisis is written in Chinese, it is make up of two characters, one symbolizes danger and the other opportunity” (p. 1). Crisis is danger because it threatens to overwhelm an individual, and it may result in suicide or mental illnesses in extreme cases. On the other hand, it is also an opportunity as it provides the client opportunities to learn new coping skills and function at a higher level equilibrium state than before the crisis.

Crisis intervention is an immediate person to person assistance. It helps people who face crisis to restore self-determination and self-confidence (France, 1996). Crisis workers assist people in crisis by searching alternatives for solutions by encouraging them to consider and clarify their thoughts, feelings and options. Aguilera (1998, p. 26) stated that the therapeutic goal of crisis intervention is to enable the individual in crisis to regain emotion equilibrium or gain higher level state of equilibrium than before the crisis.

In the event of a crisis most people tend to avoid intervention in order to stay out of trouble, however there are people who would try to intervene out of good intentions but they might not be the right person to help and may even worsen the situation. People with type A personality are not suitable for crisis work as they are very competitive, impatient and easily aroused to anger. They experience a constant urgency struggling against the clock and become impatient with delays and unproductive time (McLeod, 2011). People with such personality are not suitable for crisis intervention work as they do not have the patience to observe and understand the situation. Although speed is essential, crisis workers must have the patience to communicate with the person in crisis and not aggravate it by getting angry themselves when the problem is not solved. Hence, not everyone can be an effective crisis intervention worker.

The job of a crisis worker is to define crisis as perceive by the individual and attend to the immediate problem, which is to understand and use the fastest method to solve the problem at hand. Once the situation is in control and the person in crisis has calmed down, the case will be handed to other professionals for follow-up as crisis workers do not need to solve the root problem. In addition past experiences and the crisis worker’s personality and characteristics like life experience, poise, creativity and flexibility, energy, resilience and assertiveness affects the worker’s ability to handle different situations.

Life experiences are rich resources for a crisis worker as it comes with emotional maturity. Workers who had overcome crisis in life gain perspectives by learning from those experiences and use their experiences to help people who are in crisis like them before. Although life experience is a rich resource, it can weaken the crisis workers if it influences them in a negative way (James & Gilliland, 2008).

As the situations are often shocking, unpredictable and unexpected, crisis workers need to remain calm and steady, to provide an atmosphere that is stable and rational for people in crisis. James and Gilliland (2008, p. 22) stated that “an effective crisis worker is as steady and well anchored as a Rock of Gibraltar.” meaning that an effective crisis worker is stable and solid as stone and remains calm and collected who is not afraid, tense nor anxious during a crisis. Also, being poise is one of the significant qualities a crisis worker should have.

Different crisis requires different methods to resolve. Hence, crisis workers need to be creative and flexible when dealing with crises that are complicated and appears to be unsolvable. Although crisis workers do not have the answers to every question, they are expected to be competent in problem solving, guiding and supporting the person in crisis towards crisis solutions (Aguilera, 1998).

Occasionally, crisis workers may need to employ untraditional approaches to solve difficult situations. How creative an individual is in finding solutions during difficult situations depends on how well they have natured creativity through the course of their lives (James & Gilliland, 2008).

In addition, crisis workers need energy as crisis work is very demanding, tedious and intense who often need to assess, organize and direct situation. James & Gilliland (2008, p. 22) highlighted that crisis workers take care of themselves in both physical and psychologically, and uses wisely of their available energy.

Also, crisis workers need to have some degree of self-knowledge about their own abilities and understanding, particularly to the extent of being resilience during difficult situations, such as working with offensive or aggressive people (Trevithick, 2005). During crisis, people are often hostile and do not talk much, hence crisis workers would need to be assertive and set limits to behavior so as to keep the person stabilize and also to maintain own integrity (James & Gilliland, 2008).

As Trevithick (2005, p. 72) stated for a crisis worker to make an intervention effective, it involves being able to recommend the right courses of action, the right choice of generalist skills and the specialist interventions connected with a particular practice approach. Besides using knowledge to describe the mandate for involvement, crisis workers need to be able to set the intervention in ways that address the needs and expectations of the individual in crisis.

During threatening situations, one needs to learn how to make assessment and deal with the people involved. Hence, practicing a model for crisis intervention can help crisis workers to be aware of the components of an effective response to crisis. James and Gilliland (2008, p.37) stated that, it is worth having a model of intervention for crisis workers that is direct and effective.

James and Gilliland (2008) developed a six-step model for crisis intervention. This model focuses on listening and acting in a systematic manner helping people in crisis to regain back to an equilibrium state. The first three steps are focused more on listening while the last three steps are focused on actions.

First, defining problem is to understand the issues from view point of the individual in crisis. This requires core listening skills, congruence, acceptance and empathy. Second, ensuring safety is necessary by keeping the individual and the crisis worker safe by reducing any possibility of physical and psychological danger. Ensuring safety is a continuous part in the process of crisis intervention. Third is providing support by communicating care and emotional as well as informational support for the individual (James & Gilliland, 2008).

Fourth, examining alternatives, which is often neglected by the individual and worker, is to consider different options available to decrease the intensity of crisis and defuse the situation by selecting the best alternative that best fits the situation (James & Gilliland, 2008).

Fifth, making plans where the individual is supported to make a very detailed plan from the alternatives that are positive and achievable. Collaboration is important in order to let the individual have a sense of ownership of the plan to regain order, as France (1996, p. 48) had stated order can come to what has been a chaotic situation as the individual work on a plan; a sense of self-control and enhanced self-esteem can be attained when an individual attribute tangible progress to their own efforts and realistic hope can grow as the individual plan courses of action and experience success.

Lastly, obtaining commitment from the individual either verbally or a written commitment that can be comprehended and carried out by the individual. The goal is to let the individual commit to the plan and take definite positive steps designed for them to move towards regaining a pre-crisis state of equilibrium (James & Gilliland, 2008).

In conclusion, almost everyone can learn crisis intervention through reading books and practicing and mastering the skills in intervention, however, an effective crisis worker needs more than a strong base of theoretical knowledge and technical skills. The characteristics and the personality of a crisis worker also affect how an individual handles a crisis and it also requires great amount of energy to meet the demands of the job. Thus, not everyone is suitable to do crisis intervention work.

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An Analysis of a Range of Issues in Quality Frameworks, Processes and Methods of Measurement in Mental Health Work and Social Work Practice

Introduction

In equating the various range of issues with respect to quality frameworks, processes as well as methods of measurement in mental health work and social work practice it is important to understand the meaning of these terms as well as their respective applications in the United Kingdom, which represents the subject focus for the aforementioned. Mental health is defined as (Houghton Mifflin, 2006):

“ A state of emotional and psychological well-being …” whereby individuals are able to utilize their respective “… cognitive and emotional capabilities …” to function as members of society as well as to “… meet the ordinary demands …” which are a process of daily living”

In the context of mental health services it relates to “A branch of medicine that deals with … achievement and maintenance …” (Houghton Mifflin, 2006) of the psychological well-being of individuals. The International Federation of Social Workers (Bouldertherapist.com, 2006) defines social work as a profession that “… promotes social change, problem solving in human relationships …” as well as giving individuals the empowerment and liberation “… to enhance their well-being”. The profession, as maintained by the International Federation of Social Workers utilizes “… theories of human behavior and social systems …” in a context whereby the profession intervenes and interacts with individuals at the areas where they “… interact with their environments” and whereby the principles of both human rights as well as social justice are underpinnings in the field of social work (Bouldertherapist.com, 2006). These two fields have a denominator in common, which is that they exist to serve people and help them to improve, as well as cope with their aliments and to ultimately return to a healthful state.

The process of serving individuals in this capacity represents some of the most challenging professions in that the analysis of effectiveness, quality, processes and the methodologies utilized in measuring the aforementioned with respect to the varied issues arising from the active practice can be subjective in most instances. This examination shall look at the mental health and social work professions from the context of a range of issues representing quality frameworks, processes and methods of measurement to determine the progress made in providing better service and quality to patients and carers.

Total Quality Management

Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) are all proponents of ‘Total Quality Management’ which is a strategy dedicated to building into an organization the awareness of thinking in terms of embedding quality in all phases of an organization’s processes. The International Organization for Standardization (2006) defines ‘Total Quality Management’ as being “… a management approach … centered on quality … which is … based upon the participation of all its members … that aims at long-term success …” (Wikipedia, 2006) achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006). The preceding includes the organization itself as well as society. In equating quality, the usual context in which one thinks of this word is in products, rather than services such a those products which are made with a minimum of problems, of good materials and which work properly and achieve this through consistent operation. However, quality as an end result is an organizational mind set, and as referred to in the International Organization for Standardization (2006) definition as a process “… that aims at long-term success …” achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006).

Deming (Aquayo, 1991, pp. 6-10) is an American consultant who exposes the importance of implementing a quality oriented organization that permeates every facet of an organization’s structure and culture, regardless of department or function. Deming (Aquayo, 1991, pp. 8) states that organizations must produce “… products and services that help people to live better” and that the preceding “… is the raison d’etre …” (Aquayo, 1991, pp. 8) of the organization. His philosophy is that through the adoption of quality products and services, which is a function of management inculcating its staff in quality and innovation measures, the end product and or service improves as does its relationship with its customers and or clients. Crosby (1980, p. 1-5) indicates that mistakes or poor organizational habits and or policies are costly in terms of corrections and the damage to reputation and morale and that all members of an organization have the responsibility to perform their jobs which enhances the performance of other functions thus becoming a synergistic effect. Crosby (1980, p. 4-8), as does Deming (Aquayo, 1991, pp. 6-10) and Juran (1992, pp. 171) all emphasize the importance of quality in increasing an organization’s ability to provide services that meet and exceed client expectations through the effect that quality orientation has on internal interpersonal relationships and openness to ideas.

The heart of the work level philosophies held by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) is the contribution of ‘quality’ to the equation of improved services and innovation in heightening organizational standards. The term ‘quality’ can thus mean in this context (Wikipedia, 2006):

the excellence and or achievement of an object or service, meaning that it is not inferior or sub-standard,
a meaning of excellence in its own right

‘Quality’ is a term in this context that is synonymous with good, which represents the criteria utilized as the standard being applied. Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) equate this word in the following manner:

Deming (Deming, 1988) states that improved quality helps to reduce operating costs through less error and correction measures. He indicates that to attain the preceding a consistency of purpose needs to be inculcated throughout the organization with an overall plan that is maintained. Deming (Deming, 1988) stresses the need for improved consistency on an ongoing basis and to remove the barriers between various departments to increase and improve communication, feedback and intra-company working processes. Deming’s (Deming, 1988) thirteen point program stresses that it is management that leads and sets the example as well as supports ongoing quality through active participation that involves everyone within the organization as well as suggestions and contributions from working partners and clients.
Juran (1992, pp. 154-198) states that quality application in organizations is defined by crafting them to be utilized in context with the organizations purpose to improve performance.
Crosby (1980, pp. 189-216) also trumpets the application of quality throughout the organization as a management down function that must be maintained, taught as well as communicated to bring the staff not only on board, but committed to the adoption of quality and improvements as an organizational way of thinking.

Moullin (2002, pp. 2-7) advises us that quality in health and social care fits within these fields as it is important to:

patients as well as service users,
staff, and
the application of quality can aid in the reduction of costs as well as provide better service in the context of budgetary and cost constraints.

It is interesting to note that Moullin’s (2002, pp. 2-7) points are the same as those emphasized by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) in the general context of total quality management, and that the application in the health and social care fields is the same as for manufacturing, banking, or any other industrial sector. Moullin (2002, pp. 2-7) points out that quality in the health and social care fields is important in that not only do patients as well as service users benefit in that their differing requirements are met in a better, more comprehensive and complete fashion, the benefit of quality also affects both these groups each time they come into contact with the organization(s) and thus their individual confidence levels rise with the expectation that they will receive good service and be well treated. Moullin (2002, pp. 5) advises that patients in need of health and social services are usually stressed, worried, vulnerable as well as frightened with respect to the outcome of their need(s) and that long waits on the telephone, in lines, for responses, little or insufficient information, poor facilities and insensitivity exacerbate the preceding. He (Moullin, 2002, pp. 6-8) indicates that quality in these fields, health and social care, is important in that:

The staff benefits as the vast majority elected for a career in these fields out of a desire to help others, rather than for monetary gains and that poorly organized staffing functions contribute to frustrations for employees reducing their morale as well as effectiveness.
Moullin (2002, p. 6) adds that quality is important in the reduction of costs as he advises that the correlation between resources and quality represents a strong relationship. And while the amount and number of staffing is important, quality can be improved irrespective through the application of new innovative techniques, technology, work flow planning, scheduling and other means. Moullin (2002, p 6) indicates that reduction in costs sometimes means increasing services and or staffing in one area whereby the work load flow will thus lessen the impacts on another thus either balancing out or reducing costs through flow adjustment.

While it is difficult to place an exact date or year on when quality became an active force in the health and social care sectors, the concern over spiraling health care costs, inefficiencies and deteriorating services began to surface in the late 1970’s and early 1980’s in the United States, as well as a result of the increasing costs burdening the governments in Europe’s socialized medicine schemes (Bennett et al, 1999). The era of unlimited access and treatment as the foundation of quality oriented services in the health and social care fields began to give way to the spiraling costs of advancements in diagnostic techniques and therapeutic modalities, with the rising costs of health and social care exceeding the rise in the costs of living in the United States as well as Europe and the expenditures for socialized medicine threatened the economies of many nations in Europe (Lighter, 1999, p. 265). In addition to the foregoing, the aging of the world’s population as better medical care has increased life spans, and this combined with the fertility transition has increased the proportion of older adults and has contributed to the concern for quality in health and social care (Demeny et al, 2003). Health care spending in most OECD (Organisation for Economic Co-operation and Development) countries, such as (OECD, 2006):

Australia
Austria
Belgium
Canada
Czech republic
Denmark
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Japan
Korea
Luxembourg
Mexico
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Spain
Sweden
Switzerland
Turkey
United Kingdom
United States,

amounts to in excess of eight percent (8%) of their Gross Domestic Product (GDP), with health related spending in the United States projected at fourteen percent (14%) (World Trade Organization, 1998). The public’s concerns over increased costs for health and social care services prompted the privatization wave on the mid 1980’s in the expectation that the measure would increase efficiency as well as reduce costs, but those expectations from this initiative have been elusive (Bach, 1989). The preceding created a climate whereby governments in Europe under socialized medicine, as well as the private health care structure and governmental social care system in the United States began to look for measures to control and reduce costs while increasing quality.

In 1998 the Department of Health in the United Kingdom issued a ‘White Paper’ titled “Modernising Social Services” (Department of Health, 1998) which represented the United Kingdom governmental response to public opinion as well as mounting social care costs to introduce quality frameworks into the system. The White Paper set forth a framework at the national level that called for (Department of Health, 1998):

the establishment of “… clear objectives for social services…”that created a “… clear expectation of outcomes …” which social services would be “… required to deliver.” (Department of Health, 1998),
the publication of a “… National Priorities Guidance…” (Department of Health, 1998) that set up key targets that social services would achieve in the intermediate term, and
putting into place “… effective systems …” (Department of Health, 1998) via which to monitor as well as to manage performance.

The Department of Health’s White Paper in 1998 clearly set forth that the government of the United Kingdom was putting into place “… new resources to support …” (Department of Health, 1998) the programme, and in return for these added resources, pegged at ?1.3 billion over 1999/2000 – 2001/2002, and the United Kingdom government made it clear that it expected “… to see improvements in quality and efficiency …” (Department of Health, 1998). The Best Value framework represented another name for Total Quality Management in the context of health and social services care in the United Kingdom. Under the “Best Value” framework indicated under this White Paper, the government set forth that (Department of Health, 1998):

Local authorities were mandated to establish “… authority wide objectives for performance measures” (Department of Health, 1998) in consort with the national objectives as well as government set standards and or targets.
Local authorities were also provided with the responsibility to conduct and “… carry out fundamental performance reviews …” (Department of Health, 1998) concerning all their services in a five year framework utilizing these reviews for assessment and the establishment of “… local performance plans…” (Department of Health, 1998).
That the local planning process will be underpinned and supported via data obtained “… from a new statistical performance assessment framework” (Department of Health, 1998).
“… Local Performance Plans …” will be utilized to identify the targets for improvement compared against performance indicators on a local level and “…. The National Best Value Performance Indicators …” (Department of Health, 1998).
Annual reviews of the aforementioned local performance plans will be conducted by the Department of Health utilizing Social care Regional Offices to assess progress and identify problem areas (Department of Health, 1998).
The White Paper put into place an independent inspection system utilizing data from the performance assessment framework (Department of Health, 1998).
And lastly, the ‘Modernisation’ programme set forth a system of Joint Reviews reducing the time table to five years from seven (Department of Health, 1998).

The new programme set forth a performance assessment framework that specified performance areas defined by (Department of Health, 1998):

cost and efficiency,
effectiveness of service delivery and outcomes,
quality of services for users and carers, and
fair access.

Analytical Methods of Quality Measurement and Standards

Balanced scorecards represent a top-down hierarchical set of management tools that link long-term financial goals with performance targets (Kaplan et al, 1996, pp. 75-84). The United Kingdom’s National Health Service utilizes what is termed a ‘Star Rating’ system which is an example of the balanced scorecard (British Library, 2002). Kaplan et al (2001) advise that this methodology, specifically designed for the public as well as voluntary sectors has a link between performance measures and strategy, and thus the method should represent one of benefit in these regards. The caveat is that there are varied difficulties arising from its use by organizations as the financial perspective measurement is not the defining factors of organizational purpose in the public sector (Dickson et al, 2001, pp. 1057-1066). Kaplan et al (2001, pp. 135) agree with the foregoing and add that in utilizing the balanced scorecard governmental agencies should consider the utilization of an overarching objective at the head of their respective scorecards which is reflective of the long-term objectives (Kaplan et al, 2001, pp. 135). The difference in the utilization of the balanced scorecard in a not for profit and governmental agency mode as opposed to business is the way stakeholders are considered. In a business atmosphere stakeholders are involved as it represents the best means to conduct business, however in a not for profit and governmental agency sense, these organizations usually exist for the benefit of the users of the service as well as other stakeholders thus changing the emphasis whereby stakeholder contribution is more fundamental (Moullin, 2002, p. 167). Moullin (2002) adds that user involvement takes place at two levels, one represents helping to develop the service to meet their needs and the second entails the involvement of users and carers in the decisions concerning their health as well as the care given and received.

Benchmarking, as a term, has numerous definitions, however at its core it represents a process of “…sharing information, learning and adopting best practices …” (PSBS, 2006). The European Benchmarking Code of Conduct states that it is a process of making comparisons against other organizations and thus learning from the lessons these comparisons reveal (The European Benchmarking Code of Conduct, 1998). In the context of social care, benchmarking entails the understanding or and utilization of knowledge gained across a range of services and compilations to utilize in formulating standards of measurement as a guide to rating and understanding the performance of services in individual local authorities. The weakness of benchmarking is that it can not stand as a total measurement without revision and modification as newer and more effective techniques and methods prove themselves. Thus as a standard in a state of flux, benchmarking represents a system that is based upon existing methodologies, that are changing, being modified and or amended. Thus benchmarking represents a useful, yet temporary methodology whereby the practitioners must be mindful that existing standards are subject to change, which in conjunction with other measurement methodologies has contributed to improving quality and performance in the health and social care sectors.

Quality Approach

The utilization of balanced scorecards, and benchmarking fall under the concept of Total Quality Management which is termed Best Value under the Department of Health’s Modernization Programme and is illustrated by an example provided by Gillian Crosby (2004, pp. 7-8), the Director of the Centre for Policy on Ageing. She indicates that the problem in the social services arena, is wrongly based in concentrating on the solving of their problems as well as users of services rather than as their being active contributors to society. Crosby (2004, pp. 7-8) indicates that the NHS views social care as well as society’s older individuals as a “problem” which in what Crosby (2004, pp. 7-8) terms a “… very narrow approach …” thus creating a focus on delivering intensive services which thus “… excludes … older people and their careers”. She further states that in the aspect of quality as it relates to social services the systems of initiatives, pilots, and projects that have been created and put into place to audit, evaluate, monitor and investigate service development and provisions have been in place for years. Crosby (2004, pp. 7-8) maintains that the problem is the “… sustaining and maintaining …” these areas and “… building them into effective …” provisions through utilizing these collective findings and synthesizing that information. Crosby (2004, pp. 7-8) indicates that this void causes good ideas to stagnate rather than permitting them to be explored and utilized where warranted and she cites that quality thus suffers as a result of duplication and what she terms as “… pilot fatigue …”, indicating that the system needs to implement as well as create and find more innovative ways in which to service elder citizens in a manner whereby these initiatives are “… developed and maintained.” Crosby (2004, pp. 7-8) that there are numerous examples of individual cases whereby instances of good practice have been demonstrated through partnerships that have improved service provisions for elder citizens, citing the “London Older People’s Service Development Programme” as an example. The preceding utilized a collaborative model that promoted optimized care and independence and grew into a tool implemented by the National Service Framework for Older People in London with the hallmark being its “… single assessment process” (Crosby, 2004, p. 8).

The foregoing example is an instance whereby the practice of Best Value and allied tools need improvement to respond to the specialized needs of a segment of social care services, but this example does not indicate that system wide the measurement has not produced results. The system has shown “mixed progress” as reported by the BBC (2005) as the quality of care has improved since the adoption of the Modernization Programme, but as the BBC (2005) reports, “… there are still worrying gaps …” with regard to service as reported by inspectors. The BBC (2005) report indicated that three quarters of the council departments received ratings “… in the top two categories …” as opposed to slightly “… over two thirds in 2004”. Thus progress has been made as a result, yet there is still sufficient room for further improvement.

The NHS Mental Health sectors foundation for improvement in its quality of services was set forth under the National Service Framework in 1999 which established a blueprint for care throughout the United Kingdom …” (Department of Health, 1998). The initiatives established for a modern NHS resound with the word ‘quality’ as its foundation (Appleby, 2000, pp. 177-291). The process filters down into every job description utilizing the word “quality agenda” (Appleby, 2000, pp. 177-291) which is composed of six elements:

treating patients as well as service users with the dignity they deserve,
the creation of the proper environments via which patients can recover and utilizing their views to accomplish how services should be developed,
recognition of the skills of families in the roles of carers,
linking service activities to needs so acutely ill individuals receive urgent care access through a comprehensive range of services,
making the best as well as most effective treatments available, and
emphasize patient safety

The success of the system is contained in the regional rating system which measures the number of ‘Local Implementation Plans’ in red, amber and green (Appleby, 2000, pp. 177-291). The National Service Frameworks set measurable goals as follows (Department of Health, 2006):

the setting of national standards and the identification of key interventions with respect to defined service and or care groups,
placement of strategies that support implementation,
establishment of means via which to ensure progress in defined time frames,
introduction of the new NHS and A First Class service that re-emphasized the position of NSF’s as the key drivers in the deliverance of the modernized agenda.

The success of the NSF is assessed by what are termed interface indicators which are a part of the performance assessment frameworks which has seen demonstrated improvement throughout the system as a result of the Department of Health Modernization Programme and as contained in the Mental health NSF Performance Report of July 2005 rated all ongoing programs as meeting the prescribed targets of achievement (Mental health NSF, 2005). In 2005 26 councils received the three star top rating, which represented an increase of six councils over the prior year (BBC, 2005). The total results indicated (BBC, 2005):

83 councils received two starts as opposed to 78 in the year 2004,
31 received one star, which represented a decrease from 36 the year before,
3 received zero stars, which decreased from eight in 2004.

The foregoing indicates that the Modernization Programme has demonstrated progress and as a result of the varied programmes and measurement systems there is in place a means to equate progress.

Clinical Governance is a term and process which grew from the commercial arena under standards for financial management for companies in the private sector (Palmer, 2002, pp. 470-476). In the framework of the NHS it represents a methodology and framework whereby organizations are accountable for the continuous improvement in the quality of their services as well as high standards of care through the creation of a climate and environment whereby excellence with regard to clinical care grows (Department of Health, 1998, p. 33). Since the implementation of the Department of Health’s modernization programme NHS community and acute trusts have been charged with the creation of established structures as well as processes for clinical governance which is monitored by the CHI. It represents a comprehensive approach comprised of four areas (Palmer, 2002, pp. 470-476):

definitive and clear lines of responsibility for overall clinical care quality,
programme of quality improvement regarding activities that includes a clinical audit,
development and utilization of clear policies that manage risks,
procedural methodologies for all groups to identify as well as correct poor performance areas

The heart of the system is the clinical audit which places accountability on the managers and utilizes performance management as the process of delivering the objectives throughout organizations to filter down to each individual and job description thus providing management with clear roles and set priorities. The programme has been rated as successful in terms of it providing a clear set of measurement data to gauge and compare progress through point in time comparisons under its clinical audit segment which represents a new system that did not exist (Palmer, 2002, pp. 470-476). As such it has aided in the achievement of measurable improvements in the field of patient care, making such an established routine.

The Commission for Social Care Inspection utilizes a framework of fifty performance indicators that when assessed as a whole provide an overview of the manner in which local councils are serving the needs of their residents concerning social care service delivery (East Sussex County Council, 2006). Inspections are carried out a minimum of once in a three year period and can be conducted at any time and is comprised of three types of inspections (Commission for Social Care Inspection, 2006):

Key Inspections:

These are comprehensive and through inspections that are unannounced and are conducted at least once for all adult social care services during a year period. It represents on sire as well as documentation reviews and inspections of all areas of service categories without any prior notice.

Random Inspections

This type represents targeted specific issue inspections conducted in addition to key inspections in the follow up of complaints and or progress from an earlier inspection calling for specific areas of concern.

Thematic Inspections

These inspections represent follow up to regional and or national issues concerning medication, nutrition or similar areas and are also in addition to key and random inspections which can be conducted at any time.

The preceding inspections provide the formulation for ratings and represent a gauge on progress, standards and adherence to established policies. The performance indicators represent fifty differ areas ranging from (National Statistics, 2005):

Children’s Pls
placement stability
employment, education and care leavers education
unit cost of residential care
unit cost of foster care
children reviews
core assessments
long term stability
children in need
Adult Pls
emergency admissions
drug treatment program participation
unit costs of residential and nursing care
adults at home
services for carers
client reviews
carer assessments
waiting times

The methodology has been successful in terms of providing a measuring device via which the CSCI can assess progress and improvements as well as backward movements in services. The audit commission’s role promotes the utilization of performance data to fuel improvements in services provided to the public (Audit Commission, 2006). The Audit Commission works with varied governmental departments, agencies and local authorities to define a broad array of performance indicators applicable to their circumstances. As a department the Audit Commission’s success is represented by the performance indicators it assists in the development of for the aforementioned and is a success as these varied programs have improved the ability of these agencies, departments and local councils in assessment of the services under their charge.

Conclusion

The NHS Modernization framework has been devised to oversee and create improvement in the world’s largest government public sector health and social care programme which stands in excess of ?9 billion and is responsible for delivering a huge variety of services to every corner of the United Kingdom (Department of Health, 2006). Serving individuals in these sectors represents a demanding subjective function whereby the standards of quality and service delivery are defined by consistently improving services and new methodologies which change the standards as innovation introduces newer and improved techniques. Total Quality Management represents a technique that under the NHS Best value programme and Modernization plan of 1999 offers a means via which the system can monitor itself as well as agencies and local authorities with the foregoing fluctuating basis and improve its quality of service delivery in keeping with changes and improvements in care.

The preceding is important as a result of the lessons learned in spiraling health and social care costs that surfaced in the late 19

Work-life conflict occurs when time and energy demands imposed by our many roles become incompatible with one another; participation in one role is made increasingly difficult by participation in another. Work-life balance (WLB), from an employee perspective, is the maintenance of a balance between responsibilities at work and at home.

When the employees have conflicts between their work life and personal life it creates distractions in their work, preventing employees from performing in their best level, which creates obstacles in the achievement of organizational and individual goals. Therefore failure in managing work-life conflict among the employees could lead to problems within the organization.

Hemas Hospital is a newly started hospital in Sri Lanka in the year 2008. It is a multi specialty hospital which caters for the whole family by providing highly specialized medical services according to the highest international standards. Around 100 consultants practice in this hospital.

As a newly started hospital working for 24 hours they are confronted with problems of employees struggling to strike a balance between their work and life. Employee’s commitment to their service is vital to provide to provide a according to the standards.

At Hemas Hospital Nurses play a major role. “Professional nursing is a highly skilled practice directed towards improving the health status of individuals, groups and communities. Nursing activities encompass promoting health, preventing disease, aiding and supporting people in daily living as well as during recovery and rehabilitation, and helping people to die comfortably and with dignity” (“Nursing”, n.d.).

The purpose of this essay is to highlight and discuss on the issues of work life conflict & how it affects further to discuss about the solutions that could be applied to tackle the conflicts. Secondary researches have been used in order to support the discussion in an effective way.

2.0 Causes

2.1 Women’s Family Commitment

Over recent years there has been an enormous increase in the number of women employees entering to the paid workforce labor of Hemas Hospital Wattala. Despite the rapid growth in women’s involvement in the paid workforce; it appears that little has changed for women in terms of their family commitments.

Culture plays a big role in Sri Lanka in relation to this topic. “Traditional gender roles prescribe for women to place the role of wife and mother above all others; men are expected to be the family breadwinner. Given the burden of household responsibilities and child care, women employees (doctors, nurses, receptionists) face the demands of multiple roles, which often go beyond the general three roles working mothers generally take on (wife, mother, and worker) to include responsibilities such as: caretaker of aging parents, sister, aunt, cousin, etc.” (Scott Coltrane, n.d.)

As a result of these multiple tasks work life conflict has been identified as a common problem among most women employees at Hemas Hospital.

2.2 Personal Health Problems

Health is the general condition of a person in all aspects. Having problems is a part of life. Most of the researches have found that effects of stress affect the health. The reason is the stress and health is closely linked. And also they have found that the risk factors for health caused by chronic stress causes as much as 60 to 90% of all illnesses. The impact it has on your health, both physical and mental, can be very harmful. And individuals stress does contribute to high blood pressure, high cholesterol, and other cardiac risk factors such as addictions and obesity. We found that 55% of Hemas hospital’s nurses getting sick because of the stress they have. Some of the shifts they have to cover up without taking breaks. Therefore they cannot balance their personal lives with the work they have. So that stress arises and automatically they get ill.

2.3 Tight Work Schedules

Workers have to control their working hours to enjoy a better life. Most of time nurses have to do night duty and also they have to do over time work because of this reasons lack of flexible working hours can be arising. Most of times who worked as nurses are young mothers so then they have do their children work, they have to care about children and also their home work. It is very hard to do night duty person who has small child then they might feel time is more important than money after that there can be arise a stress on work place. Organization culture can shape the work life balance. According to our culture most of time mothers are house wife’s and also children’s need care of mothers. If mother busy with her job then there will be arises social problem and also family problems. In Hemas hospital every nurse has to do two night duties in each week and then there arises conflict between work life balances.

2.4 Lack of Employee Rewards and Appreciation

As a nurse Caring for the sick and dying has never been easy. Though it is a respected, intellectually stimulating, and deeply meaningful career today it offers limited benefits and many challenges.

Though it’s been 2 years Hemas Hospital started their management hasn’t introduced proper rewarding system for the nurses. This will directly affect the employee’s morale; therefore employee productivity would be less.

2.5 Transportation Issues

Transportation is one of the main issues that Hemas Hospital employees are facing. Since there are both day and night shifts, the employee’s main problem will be the transportation.

In Sri Lanka with the cultural situations most of the people think in negative way when the females doing the night shifts and/or when they arrives at home in mid night, Since the public transportation is not too safe for female after around 7.30 – 8.00 pm the transportation will be highly regarded when comes to night shifts.

3.0 Effects

3.1 High Absenteeism

Absenteeism is an expensive problem in both public and private sector organizations. Over the past decade, there has been increasing interest in the impact of women’s family responsibilities, personal health problems and transportation problems on absenteeism. Many women employees at Hemas Hospital find it hard to achieve their desired combination of work and family time. For example, family responsibilities appear to constrain a woman’s choice of occupation. Women taking leave due to illnesses of children or their elder parents.

3.2 Less productivity

Due to personal health problems, lack of rewards and appreciations and tight work schedules employees’ productivity getting reduced. This situation is not good for a working place like hospital. Productivity is one of the most important factors when it comes to work. When employees are not healthy they are unable to work properly. Therefore their productivity comes down and the job they do cannot be performed properly. When working in a hospital, the employees have to work very effective manner, because they are the savers of patients’ lives. It will be a big disaster if they forget or neglect to give proper medicine or giving wrong medicine to a patient. This would highly affect to Hemas hospital if they do not work properly up to the standard.

3.3 Dissatisfaction

“While the majority of “reasons” for dissatisfaction usually point to elements of the workplace itself such as: management style, environmental conditions or opportunities for growth, lack of rewards and appreciations, tight work schedules etc.” (“A guide to grow your personal growth”, n.d.).

It was found that especially nurses are dissatisfied with their job. Due to this they may move towards competitors or leave the job. Therefore Hemas Hospital has to consider ways of minimizing the work dissatisfaction.

3.4 Stress

Stress is the most hated part of the job of healthcare employees. This can be occurring due to personal health problems, women’s’ family commitments and tight working schedules. Therefore it leads nurses to be dissatisfied with their work. Due to the dissatisfaction they will not perform efficiently and effectively through less performance. Furthermore their loyalty for the company will be less and will tend to move towards competitors or leave the job.

One of the respondents at the Hemas hospital said that, “Too much pressure on this shift… Scanty facilities… very meager…you feel really exhausted…amounting to tensions and conflicts which are often displaced onto people around…you know…yelling at colleagues…”

3.5 High employment turnover

This can be happened due to all of the causes mentioned above. More than the cultural influences nursing is a more stressful and challenging job therefore it’s a must to recognize them as very precious for the hospital to make them retain in the hospital. The impact of turnover has received considerable attention by senior management, human resources professionals, and industrial psychologists.

It has proven to be one of the most costly and seemingly intractable human resource challenges confronting organizations. Analyses of the costs associated with turnover yield surprisingly high estimates. The high cost of losing key employees has long been recognized. When consider the Hemas Hospital the situation also same. It appears high employment turnover, especially nurses.

3.6 Work overload for other employees

Due to health problems and family commitment some employees cannot perform their duties to the expected level. So others will have to carry out the sick employees work load too. Some times since they haven’t time to fulfill the work load they might not do even their assigned duties properly. They do not care about the patients very well. Then again it will affect to the overall performance of the Hemas hospital.

In addition, inadequate facilities, improper functioning of other employees and neglected responsibilities created pressure and conflict among the personnel. These inadequacies eventually reduced the tolerance threshold, which in turn contributed to the conflict experienced.

One of the respondents at Hemas hospital said that, “We can’t ignore the fact that heavy workload and shortage of skilled human resources affect our performance; despite our effort to get used to the situation, we are limited in coping. When you see that the supervisor stops backing us up and never steps into the ward to listen to us it makes us feel our rights have been violated.”

4.0 Solutions

4.1 Paternity leave

Paternity leave is the time a father takes off work at the birth or adoption of a child. This kind of leave is rarely paid. A few progressive companies offer new dads paid time off, ranging from a few days to a few weeks. Hemas Hospital can arrange paternity leave for doctors and therefore can avoid the absenteeism and dissatisfaction towards the job.

4.2 Dependent care arrangements

Many nurses will be faced with issues of child or adult care giving. Without adequate support, these can create a host of distractions from work. There are many ways that the Hemas Hospital can support their nurses with their personal responsibilities. Some of the ways are on or off site child and adult care centers, lactation programs, dependent care referrals, etc.

4.3 Job sharing

Job sharing is a form of permanent part-time work in which a full-time position is divided between two or more people, each of whom shares responsibility for the entire workload. Each job sharer receives conditions of employment and entitlements on a pro-rata basis in proportion to the hours worked. Job share arrangements are suitable for both professional and academic positions. A change from full-time work to a job sharing arrangement does not break continuity of employment.

Job share arrangements can facilitate increased workplace flexibility because job sharers can relieve or cover for each other without loss in efficiency and effectiveness. Hemas Hospital also can implement this program and can get the maximum benefit out of it.

4.4 Flexible work schedules

A flexible work schedule is a type of flexible work arrangement that allows employees to vary when they begin and end their work day to accommodate their individual and family needs. This flexibility greatly eases the burden of busy employees as they try to juggle their work and home lives Flexible work schedules benefits both employees and organization it self.

For employees Increased satisfaction and productivity, reduced stress and health care costs, decreased absenteeism and reduced commuting time. For organizations improved retention and reduced turnover, higher levels of loyalty and commitment ,no change in manager’s supervisory time, attracts diverse employees who may not be able to conform to rigid schedules (i.e., disabled)

4.5 Incentives

As a result if the hospital is not rewarding nurses well the Sri Lankan culture influences them to be not loyal towards hospital and as well to perform poorly. If an employee appreciated or rewarded it will influence them to work hardly than the before and also motivate to keep the work and personal life in a balance. For that reason this is the best time for Hemas to start an appropriate rewarding and appreciation system for their nurses to make them satisfy and happy situation between work and life.

5.0 Recommendations

5.1 Short Term

Out of the number of solutions available, according to the situation, a strategy needs to be developed according to the problem but this would consume lots of time and energy to be done, So till a proper strategy is developed, in the short term the hospital can reward employing workers with an incentive programmed to facilitate them to balance their work /life.Hemas Hospital can reward financial non financial incentives to encourage their work force. Under financial incentives they can grant child vouchers and can have a special funding system for employees’ children. Furthermore the management of Hemas Hospital can introduce a transportation allowance system for the employees who come from distance areas. Under non financial incentive system Hemas Hospital can arrange family friends’ benefits or annual trips or get together, so that they have sometime to spend their leisure time with their colleagues. Furthermore nurses can be given promotions, scholarships or they can select best nurse annually to encourage nurses.

5.2 Long Term

But in the long term proper strategy should be developed to address this problem, because incentives cannot be a solution for all the problems of the employees. While developing strategies the different situations of nurses need to be considered to facilitate them. Providing a flexible work options is a good method that could be developed, because job satisfaction is directly connected to a persons work schedule, especially to a nurse’s healthy mentality it is very important when dealing with patients.

“A variety of schedule options could be made available to fit their priorities and life styles.

Full-time

Options include:

Three 12-hour shifts

Five 8-hour shifts

A combination of 8 and 12-hour shifts

Part-time

Options include:

8-hour shifts

12-hour shifts

A combination of 8 and 12-hour shifts

Weekend Program

This program is an appealing option for nurses who are in school or who care for children during the week. This option provides short-term disability coverage.

Weekend nurses work 24 hours each weekend

They receive pay equivalent to 32 or 36 hours

The schedule begins Friday at 7:30 a.m. and ends Monday at 7:30 a.m.

Casual

This option is appealing to nurses who want to work fewer hours but maintain a relationship with their unit and with Northwestern Memorial Hospital.

Casual nurses work 40 hours during a 6-week schedule

Float Pool

Nurses may choose the flexibility and variety of working on multiple units through the Float Pool. Float Pool nurses are required to work two weekend shifts per month.

Options include:

Full-time work

Part-time work

Dynamic scheduling to accommodate personal work requirements.

Schedule Choices

Many nursing units offer nurses a Self Schedule option. They are able to select the days on the upcoming schedule they want to work. When their manager creates the schedule, he or she will balance the schedule requests with current patient needs in the unit” (“Careers”, n.d.).

The best recommendation would be to make available lots of flexible work schedule options and offer the nurses with a self schedule option, so that they can use choose a schedule according to their life style. These work options should be for the mutual benefit of both the employee and the employer so that employee can fulfill their responsibility towards their work place and as well as their families.

6.0 Conclusion

There is a big difference between doing things and getting something done. Most work-life efforts by HR and work-life balance teams fail despite lots of doing. The problem is that all the doing didn’t get anything done.

If the organization wants to get something done that produces strong positive results and feedback, it should be start by taking an action in order to ensure success. Good work-life balance seems to be something that well-run firms in competitive markets do naturally. They need to treat their employees well to keep them – if not; their competitors will hire them away. Government policies on work-life balance should take this into account.

Whether the organization just introducing a work-life program or making an already great one better, the organization will be substantially improving its bottom line results and changing individuals’ lives for the better. To be an effective worker he/she has maintain a better balance in between work life and the personal life. We can see that there is a clear link between causes for the conflicts and effects of them. So that if Hemas can implement the above mentioned recommendations we think that Hemas can be the best hospital by getting the maximum use of their employees while providing them a conflicts free work life environment. Hence the entire organization and employees will be proud of the results.

The “Greying of America”, refers to the endurance in our seniors which is tugging on all the resources in our society. People are living longer healthier lives. This is a good thing and a bad thing. Are we ready to meet these demands on our society in the long term? Some believe this will be a financial burden on Medicare, long-term care, public pensions and financial programs.The aging population has multiple facets; including the financial, physical, emotional, and psychologicalneeds represented in society. There is increased question if our Social Security and Medicare System will hold out to care for this generation.How will supply and demand be met when there are fewer in the work force? How will the money in Social Security System last, when less is being put in? “A large population of the United States is old and non-working. Almost 24 percent of the population in US is over 50 years old.” http://www.naswdc.org/pressroom/features/issue/aging.asp

Officials refer to this changing time in our history as the “Greying of America”.

For a long time over population was stated in our country and others, like China. One child in China and in the United States two children were plenty, now, it seems the baby boomer generation will be the largest demographic, the older generation. Some of the baby boomers have already reached this time in their lives. Baby Boomers were born in the years 1946 to 1964. If you do the math those born in 1946 are now 67, which is retirement age or it was. Retirement age used to be 65, but as the demands on our economy, so the retirement age is pushed back. Some say 72 is the new retirement age.“Statistics project that by 2030, Americans 65 and older will actually outnumber their younger counterparts. With the aging of the “baby boomer” generation and the lengthening of life spans, both the number and proportion of older people are rapidly increasing. Many of the health related problems that contributed to decreased life span have been combated”.

http://www.naswdc.org/pressroom/features/issue/aging.

Another question is housing, some live in their homes, assisted living, nursing homes or independent living, but will there be enough structure in place to meet these growing needs? There are also the needs of the families, caring for their elderly parents, while raising their children, and working. An article written by Joan Mooney, “Housing America’s Graying Population, she states: Eighty to 90 percent of Americans want to “age in place,” either in their current home or in their neighborhood. But most homes and communities are not set up to house the elderly. And also in an interview with Henry Cisneros, former Hud Secretary, he stated, “The solution will lie not just in individual homes, but also in the surrounding communities. The number-one fear of people as they age is isolation,” said Cisneros. “They need to be able to get to the doctor, stores, parks, and other public amenities” (Mooney).

http://urbanland.uli.org/infrastructure-transit/housing-america-s-graying-population/

Another area of concern, are the growing needs for professional social workers for this demographic in our society. Will there be enough workers for all the needs characterized by this growing segment? Social workers serve as advocates for the older people and their families, providing necessary connections for the services needed. As these demographics change and grow there is a growing requirement for social workers to provide for the necessities of these individuals and their families. There are also questions about how this generation will be taken care of since the largest part of the population will be older, and less will be in the market place.

Social workers are essential to this growing segment in our population. The professional, skilled social worker, who is equipped in problem solving, can lend peace, security and hope to the individual. They are knowledgeable about how human behavior, social, financial, and cultural issues, and how they relate and affect daily lives. So, as there are economic factors that lead to nervousness about the future of our economic growth. There are also valid arguments for supply and demand. Yes there are possibly less workers in the work force, though people are working longer. There are new or growing markets for healthcare, housing, social work intervention and pharmaceuticals, among other things that will drive the economy. There is definitely going to be cause for growth in the Gerontology field. Currently this is not an area, where social workers tend to stay due to financial restrictions, among other things. In a testimony given by:

Testimony of Elizabeth J. Clark, PhD, ACSW, MPH Executive Director, National Association of Social Workers Washington, DC Submitted to the Special Committee on Aging United States Senate Hearing

She advocates encouragement, incentives for people to enter the social work arena for the elderly through providing education, and stronger rewards to gain retention in an area of service where the general social worker does not feel it is advantageous. Otherwise the shortages will be acute and lacking the professional

Worker needed to avoid a dangerous outcome, for the coming era. She also advocates education and marketing to avert the common ideas that are related to working with older generation. That it is depressing working with the sick and the dying. A perception also exists that there are few personal, professional, and societal rewards for working with older people.

Social Workers need to take an aggressive approach to change the opinions that older individuals lack value, these needs to change in the hearts of Americans and in the hearts of the people reaching this age.

It is also concluded, NASW agrees that the existing health care workforce will be inadequate to meet the needs of older Americans. They believe the Federal Government should be involved and encouraged towards loan forgiveness, stipends for students and faculty, and financial support for field placements in geriatrics to be able to attract and retain social workers and other health care professionals in the field of geriatrics.”

The reason I include large portions of this article is I believe that will support and show this so-called Greying America does not have to be a problem. It can be solved through its own counterparts. We the nation and the other surrounding developed nations can use their own resources with the help of professionals. With encouragement, marketing, education and direction people can live functional lives even in old age.

As the baby boomer generation is different in a variety of ways, this can add enthusiasm to the discussion because, this generation does not want to stop and sit in a rocking chair. Yes, as boomers age, they will put increasing burdens on the health care and financial system. There is proof that there is a shortage in practitioners in the area dealing with aged population. And there is proof that medical advances have taken place due to this encroaching segment in the population. The fact that the older generation is trying to stay younger through exercise and prevention and taking care of themselves is causing innovation in the medical industry.

It has been said that many core nations are working toward and getting honestly prepared for the rise in the elder population. There is always the concern for the impoverished segment, like elderly, single women, and some minorities that are on the fringes. But that is where the social worker can be a benefit, searching for crucial answers and direction, and educating society to the benefits age can provide, so the stereotypes can change and empower the elderly, especially in their own attitudes.

The cultural views on aging have changed also. Before this age, before the industrial revolution, our elders were given great respect. The family included the elders, grandparents in the home. They helped raise the grandchildren and provided wisdom in the home. But cultural views have changed and the older population doesn’t seem as necessary or crucial to the family and the world. The stereotype of the older population depicts them as old and feeble, they are a drag on society, in their usefulness and value. In many cultures the elders were revered and needed now they are replaced by youthfulness and vigor. They are shuffled off to nursing homes instead of being an integral part of the home.

There is great concern over finances, will our economy survive when varying resources are changing. Coming from the perspective of belonging to the ‘baby boomer generation and reading various articles, this generation was a change from previous generations. There was an increase in money to be spent and less saved. There became more emphasis on pleasure and leisure. After the depression, the financial world allowed for more to be had, with a blink of an eye. You did not have to save, before buying as our parents did. So, is this generation ready to quit the market place? Many are working longer due to the need to save and get out of debt. This can be a good thing as working enriches lives, keeps the brain sharp and hopefully the body more nimble.

So this is cause and effect, our society is living longer, less population, so we now have to control the somewhat adverse effects of an older population? Or is it an adversity? Are older people nonproductive residues in our environment? Maybe because I am a part of that generation, I believe they have contributions, yet to give. Mother Theresa was older when she passed from this world. Should she have been pushed into a corner to die? I do not believe so. She was a great asset to the community in our world. My mother, until recently resided in our home for years. Now she is in Oregon with the rest of my family, but she is valued and loved. I do not think people intend to relegate the elderly to the corner, but pressures in the home, finances and social perspective seem to guide us there.

The Social Work profession wants to work to change these notions and show people their worth, through, information, education, counselling, community assistance and many other problem solving community and government actions. What can be done to change the present outcome? We need to let people continue to contribute in their own way, so they can feel their worth. Yes, generally they cannot move as fast, even think or talk as fast as you or I. But they can show and teach us, if we are willing to learn and listen. We have learned by studying History that we can change things and have a better outcome for the future if we do not repeat mistakes. I believe when families co-existed, the family unit had a greater strength and fortitude to weather storms. Culturally, the breakdown of the family unit exists, but the foundations can still be built through relationships and assistance to the needy. Through reaching out in the community, and again this can be directed with social assistance. Social workers in this environment are trying to instill life in the elder patient and the family giving them direction, and assistance through the transition, of being the giver to the receiver as an older person is. But we can still allow them to give through their lives, if we are willing to receive.

Working in the public, networking, people are not satisfied to stop at a certain age, but press on to learn new things. There are many people re-inventing themselves at different walks in their lives, to allow for change, challenge and growth as individuals, who will benefit society. This benefit can come in the form of financial advantage and socially for our society as a whole to counter affect the challenges of a so-called decaying society. With encouragement, marketing, education and direction people can live functional lives even in old age.

Sources

Gibelman, M. (1995). What Social Workers Do (4th ed.). Washington, DC. NASW Press.

Dunkle, R.E., Norgard, T. (1995). Aging Overview. In R.L. Edwards (Ed.-in-Chief), Encyclopedia of Social Work (19th ed., Vol. 1, pp. 142-153). Washington, D.C.: NASW Press.

Zuniga, M.E. (1995). Aging: Social Work Practice. In R.L. Edwards (Ed.-in-Chief), Encyclopedia of Social Work (19th ed., Vol. 1, pp. 173-183). Washington, D.C.: NASW Press.

This assignment will look issues around older people’s mental health, in particular, dementia and abuse; this will include demographics of older people, statistics, the history, definitions and causes of dementia, and finally the lack of legislation to protect vulnerable people from harm and the implications for social work practice.

The population surge at the end of world war 2 has gave rise to an unprecedented population explosion and to what we now call the ‘baby boomers’, these people are now in their retirement years'(Summers Et al, 2006), and our population now contains larger percentage of older people that ever. In society today elder people are becoming the fastest increasing population in the UK, National Statistics (2009) states that ‘the population of the UK is ageing. Over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 per cent in 2008, an increase of 1.5 million people in this age group’. Due to the increase of the ageing population we are now seeing emerging health and social care issues in our society. Many older people will be active, involved within the community, and independent of others. However, as you get older it is natural to experience pain, a decline in mobility or mental awareness.

Mind (2010) states that ‘the most common mental health problems in older people are depression and dementia. There is a widespread belief that these problems are a natural part of the ageing process, but this not the case; it can start as early 40 but is more common in older people (Royal college of Psychiatrists, 2009), however, ‘there only 20 per cent of people over 85, and 5 per cent over 65, have dementia; 10-15 per cent of people over 65 have depression’ (Mind, 2010). It is important to remember that the majority of older people remain in good mental health. ‘Dementia mainly affects older people, although it can affect younger people; there are 15,000 people in the UK under the age of 65 who have dementia’ (Alzheimer’s society, 2010). However, ‘currently 700,000 – or one person in every 88 in the UK – have dementia, incurring a yearly cost of ?17bn, and the London School of Economics and Institute of Psychiatry research calculated that more that 1.7 million people will have dementia by 2051’ reported by BBC news (2007).

‘The word dementia comes from the Latin ‘demens’ meaning ‘without a mind’. References to dementia can be found in Roman medical texts and in the philosophical works of Cicero. The term dementia came into common usage from the 18th Century when it had both clinical and legal connotations. Dementia implied a lack of competence and an inability to manage one’s own affairs. Medical use of the term dementia evolved throughout the 19th century and was used to describe people whose mental disabilities were secondary to acquired brain damage, usually degenerative and often associated with old age’ (Kennard 2006). From the 20th century onwards scientific knowledge was supplemented through the examination of the brain and brain tissue which was founded and performed by a physician Alois Alzheimer (Plontz, 2010). The National service framework (Department of Health, 2001, p96) now defines ‘dementia as a clinical syndrome characterised by a widespread loss of mental function’.

The term ‘dementia’ is used to describe the symptoms that occur in a group of diseases that affect the normal working functions of the brain. This can lead to a decline of mental ability, affecting memory, thinking, problem solving, concentration and perception, also problems with speech and understanding (Mind, 2010). ‘Dementia is progressive, which means the symptoms will gradually get worse. How fast dementia progresses will depend on the individual. Each person is unique and will experience dementia in their own way’ (Alzheimer’s society, 2010). Symptoms of dementia include: Loss of memory, Mood changes, and Communication problems. In the later stages of dementia, the person affected will have problems carrying out everyday tasks, and will become increasingly dependent on other people, two thirds of people with dementia live in the community while one third live in a care home (Alzheimer’s society, 2010). There are many types of dementia, and some of the causes of dementia are rarer than others, Alzheimer’s disease is the most common cause, damaged tissue builds up in the brain to form deposits called ‘plaques’ and ‘tangles’, these cause the brain cells around them to die (Royal college of Psychiatrists, 2009). Other most commonly known is vascular disease, Dementia with Lewy bodies, Fronto-temporal dementia. Mostly, patients themselves do not present to the clinician with dementia, owing to gradual onset and denial of the problem. There is no cure for dementia but there is medication that will help to slow down the progression of the disease. When finding help for dementia it is usually the primary carers, caregivers, supporters, partners or family members who initiate asking help and a diagnosis (Brodaty, 1990).

Depression may be misdiagnosed as dementia the difference being that people who have depression are more likely to be aware of their issues therefore are able to discuss them, whereas someone with dementia may not be able to do this due to their symptoms. Nonetheless, the Mental Capacity Act (2005) states that every person has the right to make their own decisions and must be assumed to have capacity unless otherwise proven and people should be supported to make any decisions. Under the MCA, you are required to make an assessment of capacity before carrying out any care or treatment (Office of the public guardian, 2009). The Mental capacity act is an act that protects individual rights and ensures that the person’s liberty is not taken. ‘It is based on best practice and creates a single, coherent framework for dealing with mental capacity issues and an improved system for settling disputes, dealing with personal welfare issues and the property and affairs of people who lack capacity. It puts the individual who lacks capacity at the heart of decision making and places a strong emphasis on supporting and enabling the individual to make their own decisions’ (Office of the public guardian, 2009). However, even with a structure in place to protect individual’s rights and liberties many people who have dementia are more vulnerable to abuse due to their lack of capacity. The University College London research revealed that a third of carers admitted “significant abuse”, in total 115 carers reported at least some abusive behaviour, and 74 reported more serious levels of mistreatment (Cooper et al, 2009). Caregivers can also be on the receiving end of verbal or physical abuse directed at them by parents or spouses who are confused and angry over declining mental capacities due to stroke and Alzheimer’s disease. In some cases, Alzheimer’s disease or other forms of dementia may cause the patient to be uncharacteristically aggressive (Coyne, 1996).

It is only in recent years that abuse of the elderly has become more apparent, Crawford Et al (2008, p122) argues that over time it has very slowly come to the attention of people in the last 50 years that abuse does actually exist behind closed doors; in the 1950’s older people lived in large families where issues were hidden, and in the 60’s to 70’s older people started living alone or in residential homes and it was not until the early 80’s that abuse had started to be recognised and defined. Penhale and Kingston(1997) argue that over the years it has been difficult to emphasise the issues of abuse due to not finding a sound theoretical base to which an agreement of a standard definition can be made and applied. Action on elder abuse (2006) defines elder abuse as ‘A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’. Abuse comes in not just physical abuse it comes also in sexual, psychological, neglect, discrimination and financial as well. ‘Older people may be abused by a wide range of people including family members, friends, professional staff, care workers, volunteers or other service users, abuse can also be perpetrated as a result of deliberate, negligence or ignorance’ (Royal pharmaceutical society (RCA), 2007). Abuse can occur in a variety of circumstances and places such as, in own home, in a residential or day care setting or hospital and can by more than one person or organisation. Pritchard (2005) asserts that we will never have a true picture of the prevalence of elder abuse due to the unreported cases, and can only count ones that are known to organisations and services.

Most abuse is still unreported due to victims being frightened, ashamed and embarrassed to report the abuse, not realising their rights or not being able to due to tier mental health. Summers et al (2006, p7) points out that ‘those statutes that make abuse criminal are often ineffective due to them not being utilised by the victim’, and this means that this will be the biggest challenge and barrier for change in getting people to recognise the scale of the problem and raising awareness so that the government agree to change the legislation to protect older people. Abuse of any kind should not be ignored and there should be legislation to protect adults from abuse like there is in child protection, people who recognise the extent of elder abuse argue why should adults be treated as second class to children, is their suffering and deaths any less important? The Alzheimer’s Society (2010) states that ‘abuse of people with dementia should be considered in the same way as child abuse’.

Crawford and Walker (2008, p12) state that ‘prejudice refers to an inflexibility of the mind and thought, to values and attitudes that stand in the way of fair and non judgmental practice’. Thompson (2006, p13) defines discrimination as the process in which difference is identified and that difference is used as the basis of unfair treatment. A barrier to recognising the abuse of people with dementia and older people is that of social stigma, negative perceptions and connotations of words for mental health, such as confused or senile. ‘Confused is something that we all experience at some time in our lives, whereas senile is a more complex word and the first recording of its usage was neutral meaning pertaining to old age, but now has negative connotations linked to mental decline due to age (Crawford and Walker, 2008). Therefore, challenging people’s perceptions needs to done to change these social constructs to enable a change in legislation and protection of vulnerable adults. In March 2010 the department of health ran a series of campaigns to address poor public understanding of dementia which included TV, radio, press and online advertising featuring real-people with dementia (Department of health, 2009).

In 2009 the first ever dementia strategy was launched that hopes to ‘transform the quality of dementia care, It sets out initiatives designed to make the lives of people with dementia, their carer’s and families better and more fulfilled It will increase awareness of dementia, ensure early diagnosis and intervention and radically improve the quality of care that people with the condition receive. Proposals include the introduction of a dementia specialist into every general hospital and care home and for mental health teams to assess people with dementia’ (Department of health, 2009). However, this is not legislation it is just a strategy for dealing with people with dementia. The government are recognising that there is little protection for vulnerable adults and that further legislation need to be put in place and stating that dementia care is a priority (BBC news, 2007). At present, there is no one specific legislation which directly protects vulnerable adults, instead the applicable duties and powers to assess and intervene are contained within a range of legislation and frameworks, such as the Mental Capacity Act 2005 and Mental Health Act 2007 and the national service framework for older people. ‘One of the themes for national service framework (NSF) is respecting the individual which was triggered by a concern about widespread infringement of dignity and unfair discrimination in older peoples access to care. The NSF therefore leads plans to tackle age discrimination and to ensure that older people are treated with respect, according to their individual needs, specifically in standard 2 it relates to person centred care ‘ (Crawford and Walker, 2008, p8).

And expectation of NSF is that there must be systems and processes put in place to enable multi agency working. In 2000 the government published ‘No secrets which is guidance that requires local authorities to set up a multi agency framework which includes health and the police with a lead person (adult social care) to carry out procedures into the allegations of abuse whilst balancing confidentiality and information sharing’ (Samuel, 2008). No Secrets is only ‘guidance and does not carry the same status as legislation, the LA’s compliance is assessed through an inspection process, therefore the LA can with good reason choose to ignore the guidance’ (Action on elder abuse, 2006). This has concerned agencies who want to see the protection of adults given the same equivalent priorities as child protection and think that legislation is the only way to accomplish this.

A review of No Secrets guidance has been carried out in 2008 and consulted with over 12000 people (Department of Health, 2009), the report found that over half (68%) of the respondents were in agreement to new safeguarding legislation and 92% wanted local safeguarding boards to be placed on a statutory footing and still there is no legislation to protect vulnerable adults (Ahmed, 2009). A recent article in community care told the failure of the government to commit to making a policy has only strengthened campaigners fight and given rise to criticism (Ahmed, 2009).

The need to protect vulnerable people brought about the protection of vulnerable adults scheme (POVA) which is run by the Department of Health to regulate and monitor the employment of staff in the social care workforce, through this scheme a list of people who are unsuitable to work with vulnerable people is kept. More recently, the Safeguarding of Vulnerable Groups Act 2006 which was launched in 2008 replaced POVA with the Independent Safeguarding Authority (IDeA, 2009). The problem with this is that abusers of dementia sufferers are usually family member or informal carer that are under considerable stress and may not receiving help from within the health and social care system, therefore, an abusive situation can carry on for some time until the situation is found by an outsider. This situation may only be found when a informal carer starts asking for help, and when informed of the situation it is good practice and essential to make sure that carers are getting the help they need which can prevent the abusive situations. Under the 1995 Carers (Recognition and Services) Act carers are entitled their own assessment of need and by doing so this may allow for respite or payments to be made for their services (Parker Et al, 2003). University College London researchers who interviewed people caring for relatives with dementia in their own homes stated within their research that ‘Giving carers access to respite, psychological support and financial security could help end mistreatment’ (Cooper et al,2009). When working with relatives who are carers it is important to remember who is the service user, although it is important to ascertain the wishes of the relative it should not override the wishes of the service user, this is especially true when there is a break down in the care of the service user and the carer wishes the service user to be placed in care.

Many older people with dementia receive care in a residential home; this may be due to family member no longer being able to cope with the care of the person. The local authority has a duty to assess the needs of a person with dementia ensuring that their wishes are heard and adequate care is put in place. ‘Assessment is an ongoing process, in which the client participates, the purpose of which is to understand people in relation to their environment; it is a basis for planning what needs to be done to maintain, improve or bring about change in the person, the environment or both’ (Anderson Et al, 2005).

The trouble with placing people with dementia in care homes is there are not enough care homes specifically for people with dementia and people end up in a home that do not have trained staff to cope with individual needs of someone with dementia, therefore, people s wishes may not be heard. As part of the joint assessment process it is the social workers role to ascertain the wishes of the individual, this is done by assessing their needs in an holistic way which includes and medical and social aspects of the person. If there is doubt as to the mental capacity of the person then a mental capacity assessment will need to be acquired by asking to joint assess with community psychiatric nurses (CPN). Priestley (1998) states that ‘the community care reforms established the principle of joint working between health and social services authorities as a priority for effective care assessment and management with social services taking the ‘lead role’.

In conclusion there seem to have been many shifts in the direction of how policy and procedures framework and guidance care for people with dementia, although there is still no firm legislation to protect them. However, there seems to be more recognition of the issues that surround dementia and future goals are towards the training of people to understand those issues so that professionals are able to deal with the complex needs of a person with dementia.

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This essay will discuss the complex issue that is self harm in society today; although word count will restrict many of the areas this essay will try and achieve an overall balance. The essay will look at the psychological causes and treatments available to service users via the National Health Service. It will be necessary throughout the essay to compare the issues surrounding self harm with that of parasuicide and suicide itself. Consideration will also be given to the views and perspectives of the service user with regard to the service they receive and where appropriate this essay will refer to practice experience to provide depth and insight into aspects of the discussion. Reference will also be made to the links with self harm in the animal kingdom. This brief discussion with animal self harm will be an attempt to show dual causation in humans and animals. Highly concise introduction, well done.

In order to better understand self harm this issue must be clearly defined as to avoid inaccurate and misleading terminology as self-harm covers a wide range of behaviours some of which are directly related to suicide and some are not. Self harm (SH) or deliberate self harm (DSH) including self injury (SI) and self poisoning (SP) is defined as the intentional direct injury of body tissue without suicidal intent (Laye-Gindhu, A 2005., Klonsky, E.D 2007., Muehlenkamp, J.J 2005). Self harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR) (1994) as a symptom of borderline personality disorder. However, patients with other diagnosis may also self harm including those with depression, and anxiety disorders, substance abuse, eating disorders post-traumatic stress disorders, schizophrenia and several personality disorders. Self harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. (Klonsky, E.D 2007). Guidelines for the treatment of self harm are not specified from NICE.

What is self harm, self harm is deliberate damage of the body that is intentionally not life threatening, often repetitive in nature and usually considered socially unacceptable, 80% of self harm involves stabbing or cutting the skin with a sharp object (Greydanus, & Shek, 2009). It is generally agreed that someone does not intend to die as a result of his or her self harm. However, many acts of self harm are not directly connected to suicidal intent they may be an attempt to communicate with others to influence or to secure help or care from others or a way of obtaining relief from it difficult and otherwise overwhelming situation or emotional state (Hjelmeland et al., 2002). Walsh and Rosen (1998) in discussing the difference between self mutilation and parasuicide have noted; “In the case of ingesting pills or poison, the harm caused is uncertain, unpredictable, and basically invisible. In the case of self lacerations, the degree of self harm is clear, unambiguous, predictable as to course, and highly visible” (Walsh, B.W., Rosen, P.M 1988). However someone who self harms is 50-100 times more likely to attempt suicide than someone who does not (Martinson, D. 1998).There are many reasons why people self harm, in a survey conducted of young people aged 16 through to 25 the most common reason was “to find relief from a terrible situation” (Samaritans 2001).Self harm is often associated with a history of trauma and abuse including emotional abuse, sexual abuse, drug dependence eating disorders or mental traits such as low self-esteem or perfectionism. (Swales, M. 2008)

Emotionally invalidating environments where parents punish children for expressing sadness or hurt can contribute to a difficulty experiencing emotions and increased rates of self harm (Martinson, D. 2002). Abuse during childhood is accepted as the primary social factor as is bereavement, and troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. In addition some individuals with pervasive developmental disabilities such as autism engage in self harm, although whether this is a form of self stimulation or for the purpose of harming oneself is a matter of debate (Edelson, 2004)

It is noted that Service users who self harm give broadly three reasons for their behaviour these are, controlling mood, regulating moods in terms of how a person is able to cope with emotions and feelings especially feelings which are particularly unsettling unpleasant or intense. Communication, some people use self harm as a way of expressing themselves if those expressions are directed at others this can be seen by some as attention seeking and manipulation. Understand in what an act of self harm is trying to communicate can be crucial to dealing with it in an effective and constructive way. Control/punishment, people who self harm have often experienced traumatic experiences in their lives including emotional physical or sexual abuse. (Martinson, D. 1998). Self harm can be a form of trauma re-enactment or way of bargaining or engaging in magical thinking “if I hurt myself I will prevent the thing I fear protect the person I care about”. A common belief regarding self harm is that it is an attention seeking behaviour however in most cases this is inaccurate. Many self- harmers are very self-conscious of their wounds and scars and feel guilty about their behaviour leading them to go to great lengths to conceal their behaviours from others (Mental Health Foundation 2006).

People diagnosed as having certain types of medical disorder are much more likely to self harm in one survey of a sample of the British population people with current symptoms of mental disorder up to 20 times more likely to report having harm themselves in the past (Meltzer et al., 2002).People diagnosed as having schizophrenia are most at risk and about one-half of this group will have harmed themselves at some time. When assessed the majority of individuals engaging in self harm will be diagnosed with depression although two thirds will no longer fit the criteria after a year. This explains why nearly half of those who present to an emergency department meet criteria for having a personality disorder (Haw et al., 2001). However, there are problems with doing this because some people who self harm consider the term personality disorder to be offensive and to create a stereotype that can lead to damaging stigmatization by social care workers (Babiker & Arnold, 1997., Pembroke, 1994). About one in six people who attend an emergency departments following self harm will harm themselves again in the following year (Owen et al., 2002).

For the last 25 years it has been NHS policy that everybody who attends hospital after an episode of self harm should receive a psychological assessment (Department of Health and Social Security, 1984).While psychological assessment includes several components, the most important are the assessment of needs in the assessment of risks. The assessment of needs is to each item to identify those personal (psychological) and environmental (social) factors that might explain an act of self harm; this assessment should lead to a formulation, based upon which a management plan can be developed. Despite the importance of comprehensive assessment following an act of self harm many service users “fall through the net”. In many hospitals, more than half of the attendees are discharge from the emergency department without specialist assessment (Termansen & Bywater, 1975; Thomas et al., 1996; Kapur et al., 1998). Patients who leave hospital direct from an emergency department and especially those who leave without a psychological assessment are less likely to have been offered to follow- up (Owens et al., 1991; Suokas & Lonnquist, 1991; Gunnell et al., 1996; Kapur et al., 1998). In addition, those who do receive the psychological assessment (rather than the needs or risk assessment specifically) may be less likely to repeat an act of self- harm (Hickey et al., 2001; Kapur et al., 2002). These figures suggest that the service user is being set up to fail or more directly not being correctly diagnosed and treated properly.

Service user’s experiences and attitudes to the services they receive can vary but most feel like the following quotation “Got no help at all. All they wanted to do is pick on me like I was a naughty little girl, and it made me very angry, and I couldn’t open all for how they treated me. I just dreaded going to see them (Harris, 200). Not only do these kinds of attitudes make users experiences of services unpleasant, but they can also increase service user’s echoes of distress. Not only are service users critical of emergency department staff, but patients admitted to hospital following self poisoning also feel isolated, ignored and inhibited by staff (Dunleavey 1992) a fast tracking of service users through the system should be considered to minimize harm resulting from their injury and to minimize distress. Service users also point out the importance of being listened to by staff even when the interaction is brief or only a single occasion (Arnold 1995). A safe environment and being listened to it especially important since service users may reveal information about their injuries that makes them feel vulnerable, fearing negative repercussions. As a result of poor stuff attitudes towards people who self harm, service users feel that they are frequently treated differently compared with service users who have not self harmed.

“I was told off by nurses and the doctors; I just felt small. They do treat self harmers different to accident people. We are classed as suicides. The hospital staff just look at you as though you’re wasting time. That’s how I felt. (Harris. 2000).

Some self harmers, however, use the practice of self harm in a ritualistic way. This type of self harm has been practiced by different cultures for centuries, for example the Maya priesthood performed auto- sacrifice by cutting and piercing their bodies in order to draw blood (Gualberto, A. 1991). It is also practiced by the sadhu Hindu ascetic, in Catholic mortification of the flesh, in ancient Canaanite mourning rituals as described in the Ras Shamra tablets and in the Shi’ite annual ritual of self-flagellation, using chains and swords, that takes place during Ashura where there Shi’ites sect mourne the martyrdom of Imam Hussein (Reference).

Another little known fact is that the animal world is prone to self harming and there is some correlation between animals and human beings on this issue. Self -mutilation in non-human mammals is well-established, although not a widely known phenomenon and its study under zoo or a laboratory conditions could lead to a better understanding of self harm in human patients (Jones, I.H., Barraclough, B.M. 2007). Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self harm in higher mammals. Lower mammals are also known to mutilate themselves under laboratory conditions after administration of drugs (Jones, I.H., Barraclough, B.M 2007). In dogs, canine obsessive compulsory disorder can lead to self inflicted injuries, for example canine lick. Captive birds are sometimes known to engage in feather plucking causing damage to feathers or even the mutilation of skin or muscle tissue (20..?..) A good example of feather plucking in birds would be battery hens that are kept in cages with no access to movement or sunlight. Useful analogies!

Many people who engage in self harm do so not that they intend to take their life or that they are seeking attention. People who self harm do so because they are looking for some form of relief from their situation. As a coping mechanism, self harm works for the person doing it. (Reference needed on coping mechanisms) Many self harmers who seek help in the form of medical attention face an uphill struggle in the face of adversity, negativity and disbelief from the service that is in situ to help them. Negative attitudes from medical staff and social care workers affect the self harmer and they feel increasingly isolated. Within the medical profession comes a coldness not afforded to accident and ill people, along with a lack of understanding and a lack of training. Communication with the service user as well as empowerment would enable service users to have a greater say in their treatment and rehabilitation and this would go a long way in addressing this problem. Service users know why they self harm but feel they are not being listened to. Until this issue is addressed the problem will go largely unchanged. (Need references for stigma and self harm treatment in A & E)

A referral has been made by the PSNI because they are concerned about two children aged 18 months and 4 years old following their attendance at an incident of domestic violence the previous Saturday evening. Area Child Protection Committee (ACPC,2005, 9.25) state “Child protection is everyone’s business” . Gateway teams have been established within the five Health and Social Care Trusts in Northern Ireland, to deal with all referrals both from professionals and members of the public who are concerned about a child’s well being.

Social work is a profession that embraces the principles of The Human Rights Act 1998(HRA). The Children Order (Northern Ireland) 1995 (Order 1995) underpins all aspects of the powers and duties of the social work mandate governed by social work law. The Northern Ireland Social Care Council (NISCC) code of practice reflect profession ethical and values which are intertwined with law, societal values and are at the heart of how workers conduct their practice.

Article 66 of the Children Order places a duty on workers to investigate all allegations or suspicions of abuse likely to cause harm to a child. The Family Homes and DV (Northern Ireland) Order 1998 has been incorporated into the Children Order. Article 12 A, identifies the ‘risk of harm to a child from witnessing DV,’ (Order, 1995). The social work role is to assess and intervene if a child is in need or at risk of significant harm.

“Article 17 of the Order defines a child in need as unlikely to achieve or maintain a reasonable standard of health or development without the provision of services by the Health and Social Services Trust or if the child is disabled” (Order, 1995).

Upon recite of this referral the worker must take time to “tune in” to the potential risks and appropriate action as a result of this information. The worker needs to contact the PSNI and clarify the details of the referral including the severity of the DV. Multi-agency working is a key function of social work in the area of child protection and fundamental to assessment of risk. Joint working protocols exist between the PSNI and workers in Northern Ireland. The lone working policies acknowledge, violence against workers is not unheard of and the PSNI will accompany the worker to enable them to carry out the initial assessment if needed. NI is a country emerging from conflict; however, stereotypical attitudes and beliefs about the PSNI and some members of the community are deep rooted. The worker needs to assess how s/he can proceed safely.

According to the Order 1995, the welfare of the child is paramount. Social workers try to build positive relationships with parents and families. The Article 8 European Convention of Human Rights offers, “aˆ¦ protection for a person’s private and family life, home and correspondence from arbitrary interference by the State,” (www.yourrights.org).

An over authoritarian approach may serve to alienate parents but this does not mean the worker takes “unnecessary risks regarding her own or others safety”, (NISCC, 2004, 4.3).

The social worker is obliged to screen details of the people involved against the e-information system and the child protection register (CPR), for current or previous social service involvement. Names of the children need to be entered individually; it is not uncommon for one child in a family to be registered and another not. If the family or children have had previous involvement with social services and the case is now closed the manual records need to be accessed and read. If the worker has any ambiguity about the interpretation of the information, clarity must be sought with the principal social worker or whoever is the relevant party.

“Workers are accountable for the quality of their work.” (NISCC, 2004,6.0) At present the worker has no way of identifying the level of risk posed to these two children. DV is a contributory factor in half of all the serious case reviews and 75% of the cases on the child protection register. (Hester, et al.1998).

When all background information is gathered the worker needs to communicate her findings both in writing and verbally to the supervisor/team leader/manager, whom in turn has ultimate responsibility for prioritising the referral based on the available information.

Failure to follow the risk assessment policies and procedures and effectively use information can have fatal consequences for the service user. If this referral was to result in a child/ren getting harmed the social work could be held personally culpable. “Ignorance is not an excuse”, (Stafford and Hardy 1996 cited Calder, 2003, p.8).

Brearley, 1982, suggests risk is calculated by the likelihood of the variation of possible outcomes

“Past knowledge provides a reasonable basis for prediction of harm.” Stafford and Hardy (1996 cited Calder, 2002, p.8.)

The Children Order, Cooperating to Safeguard Children, 2003 and Our Children and Young People Our Shared Responsibility, 2006-2016 expresses the need for workers and all professionals to communicate. Partnership recognises the expertise of other professional’s and agencies, including the parents when it comes to the protection of children. (NISCC, 2004,6.7)

The ACPC policy states a

“child must be seen and spoken to by the worker within 24 hours and that an initial assessment of need is completed within 7 working days of receiving the referral ” (ACPC,2005,para 9.25).

The worker will undertake the initial assessment with the family. Milner and O’ Byrne (2002) describe social work as a goal directed activity. The worker needs to know the possible impact of DV on the health and development of children this age and be able to recognise the signs and symptoms of abuse.

The NISCC code of practice states a “worker needs to adequately prepare and plan all aspects of work”, (NISCC, 2004 6.4).

According to Parker and Bradley, (2003) assessment is a balance between art and science. There are no scientific tools, which can predict human behaviour or eliminate risks totally. Social work training and education equip social workers with the knowledge and skills to practice. (NISCC, 2004)

The social work profession is grounded in the humanistic principles before any direct interaction takes place the worker needs to reflect on what the serious nature of what she is intending to do.

In the area of child protection there is a considerable power imbalance between the worker and service user. The worker is effectively calling the competency of the parents into question. Workers could expect parents to be less than welcoming. It is hardly surprising given the invasiveness and instructiveness of the investigative role of child protection.

“People may feel intimidated and fearful that their children might be taken into care. This can result in hostility, anger and resentment towards the worker.” (Adams, et al, 2009 p224).

According to Farmer and Owen, (1995) Mullender, (1996) and (Mc Williams and Mc Kiernan (1995), DV is always about power and control. Their research is overwhelmingly based on male to female abuse but they do acknowledge the existence of violence against men and reciprocal violence. The worker needs to be consciously aware of this and respect the marginalized and vulnerable position of victim and abuser of DV. The worker needs to modify her own practice to address these issues sensitively and in a manner that will not further the oppression of the victim.

Various trains of thought exist as to whether empathy is a character trait or a learned skill that develops through continuous practice but it is crucial that the worker understand the importance of the perspective of the service user. Schulman 1984(cited in Cournoyer. p.22) states,

“Preparatory empathy involves “putting yourself in the clients shoes and trying to view the world through their eyes”.

Beckett and Maynard (2005) believe in the name of respect, parents have a right to know why their family is being investigated and why the worker wants to see and speak to their children. Informing the parents of their rights, including their right to complain, taking time to explain the investigation process and taking time to actively listen to parents and encouraging them to express their views will at least go in some way to upholding public trust and confidence in the social work profession. The involvement of the gateway worker will be time limited. If this family need further intervention the gateway worker needs to set the precedence for further social work involvement. If a family have a negative experience of one social worker they are likely to perceive all social workers to behave the same. Cleaver, et al (1995) stresses the need for the worker to be open and honest from the start of the process, if any trust is to be established.

Much of the assessment relies on participation of the parent, without which the worker will have great difficulty making an accurate assessment and as a result the children or the family may not get the support they need and the appropriate intervention to either meet their needs or keep them safe. (Parker and Bradley, 2003)

In the spirit of social justice and ethical practice holding the balance between the safety of the children, the importance of family life to a child and the need to avoid unnecessary interference underpins every part of the Children’s Order as it applies in practice (Children Order, 1995).

Professional ethics requires the worker to critical reflect at every stage of the process in order to think logically and make sense of what is happening.

Awareness of their own prejudices and discriminatory attitudes and a willingness to challenge them means the worker can begin to approach this family in a genuine and anti oppressive manner. According to Preston-Shoot and Agass (1990, p38)

“reactions can be determined by the workers own personal history and current emotional experiences”.

A worker who has grown up in a home where DV has been an issue may have very different feelings compared to a social worker who has never had personal experience of DV.

Workers have a professional duty under the NISCC codes of practices and in the interests of social justice not to just maintain but promote the dignity and worth of all services users. Banks (2006, p3) states, “Professional values need to distinguish between personal values.” If the worker has concerns she can explore them through supervision either with her team or senior.

Pauline Hardiker has developed the single assessment framework tool for assessing the needs of children-Understanding Needs of Children in Northern Ireland (UNOCINI) tool. The UNOCINI adopts an holistic view to assessing the needs of children. It has three interlinked areas of assessment. The needs of the child, the capacity of their parents to meet their needs and the wider family and environmental factors, such as employment and housing issues are assessed as having an impact the child’s life and well being. Our Young People Our Shared Responsibility, 2006-2016 is the Governments Ten Year Strategy’s pledge, which reflects the prevention through early intervention social policy ethos and parental responsibility and partnership principles of the Children Order are fundamental to the UNOCINI. Social workers have an ethical commitment, to promote social justice and equality to support parents in need, to bring up their children.

The aim is early identification of need, purposeful intervention, with the objective of preventing difficulties escalating and promoting the strengths and resilience of the family. Threshold of needs correspond with risk. The thinking behind this is to promote a shared understanding between professionals to identify concerns, risk, needs and strengths, particularly in the area of communication. DV is cited in threshold three of needs, (DHSSPSNI, 2007).

Mullender et al, (2004) believes children face three risks: the risk of observing traumatic events, the risk of being abused themselves, and the risk of being neglected.

Jean Paiget (1896-1980) is instrumental in constructing the idea that healthy children develop through a serious of ordered sequences, known as milestones. No two children will follow exactly the same pattern but it would be reasonable to expect that a child of 18 months would be starting to talk, walk and explore their environment. A 4-year-old would be able to walk, talk in sentences, and be out of nappies. Osofsky, (2004,p4) stresses, “Trauma due to domestic violence interferes with a child’s development.” Mullender et al (2004) whilst agreeing with Osofsky suggests that protective factors, such as a supportive not violent adult, a placid temperament and the child’s young age and lack of ability to full appreciate what is happening might help reduce the risks to children. She does point out that each child is different and will respond differently. Professional ethics and values of the social work profession emphases the need to “treat each child as an individual” (NISCC, 2004, 1.1).

“The key factors in the parenting and child domain are basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries and stability.” (Howarth, 2004,p24)

A report by Davenport in 1984 cited in Howarth (2004) discovered DV has a very negative impact on the mental health of the victim. Parents are more likely to respond with irritability and anger or fail to respond at all, rendering them emotionally unavailable to their children.

Attachment theory believes that if a child’s primary attachment is damaged in the first or second year of their life they are at significantly increased risk of developing problems later in life.

Fahlberg (1991, p.64) states

“The primary task to be accomplished during the first year of life is for the baby to develop trust in others and aˆ¦ explore their environmentaˆ¦ children growing up in a violent household may be too frightened to show inquisitiveness.”

Humphrey’s et al (2006) explored the emotional turmoil of children drawn into participating in the violence leaving the child confused and afraid and the parent undermined as a valued human being in their own eyes and the in the eyes of the child.

Humphrey’s has also drawn attention presumed attitudes that expect all mothers to love their children and treat them the same. The child that looks like the abuser or the child that is born as a result of rape may be more vulnerable to harm than the child who is none of these things.

Maslows higher hierarchy of needs believes that a child needs to feel safe and have a sense of belongingness within their family if they are to achieve their full potential, (Hoghughi and Long, 2004). Without this they are unlikely to achieve their full potential.

Smale and Tuson, (1993 cited Coulshed and Orme 1998) recommend the exchange model where all people are seen as experts on their own problems and the emphasis is on the exchange of information rather than the worker being the expert.

Listening is a core skill of any communication process. Social workers have been ridiculed in the past for their ‘know it all’ approach, often leaving families stigmatised and traumatised because of their investigations but without any purposeful intervention.

Lord Lamming (Laming report, 2003 cited in Wilson and James, 2008, p.254) following the death of Victoria Climbe, is clear that the

“aim of communication with children or about children is to gain a comprehensive understanding of a day in the life of a child”.

Children may engage through play. The worker could ask the child what TV programmes they watch or who makes dinner or puts them to bed. DV is not just about controlling people it involves controlling the household movements. The social worker needs to maintain vigilance for any visible signs of injury and needs to ask the child what happened.

Workers should engage parents at every stage of the process. The worker needs to ask the parents permission to share and collate the information; however, regardless if they agree or not the information will need to be shared in the interest of child protection.

All social work involvement needs to be proportionate to the age and developmental needs of the children and the nature and severity of the risks, concerns and strengths of the individual child and their respective family.

Farmer and Owen, (1995, p79) has highlighted that

“in the face of allegations couples often from a defensive alliance against outside agencies”.

They may have conflicting and confusing feelings of love and hate towards each other. Thompson,(2006) advised couples often have “multiple truths” of events and experiences. This advises the worker not to be drawn into giving personal judgements or opinions.

Thompson,(2006) focuses on the personal, cultural and structural model of oppression, (PCS) which might explain why women do not leave. Dobash and Dobash, (1979 cited in Cleaver, 1999) suggest that on a personal level women feel shame and guilt; they know their children are affected and they don’t report DV or seek support because they fear they will not be believed or that they may be killed for reporting it. The impact of violence can lead to the woman feeling worthless and isolated.

Culturally women are brought up from childhood to be caretakers, to comfort others and as a result of this they may believe that they are responsible for the abusers attacks, if they were a better wife, mother, cook, and then the violence would stop. The patriarchal nature of society often sees many women dependant for finance on a man. Thompson (2006) remarks, bring a child up in poverty is not impossible but it is hard.

Structurally, the lack of affordable housing and a lack of confidence in the legal system are barriers that prevent women from leaving an abusive partner. Family Homes and DV (Northern Ireland) Order 1998,Article 29 gives courts the power to remove an suspected abuser from the family home instead of removing the children. (Children Order, 1995) but this does not guarantee safety.

The new Government have warned of social welfare cut backs; the worker has to balance the needs of the family against available scarce recourses. Banks (2003 p101) states,

“a worker needs to be able to challenge agency policies and practicesaˆ¦Professional code of ethics along with education will have a role to play in this.”

A worker needs time to complete an accurate assessment. Heavy caseloads and a lack of resources have contributed to failure to protect in the past.

Empowerment is about actively finding ways that the victim can make use of intervention to help themselves move towards the survivor role and care and their children without the support of the state.

Conclusion

Accurate, precise recording are vitally important to child protection and helps build the picture of children’s lives. The risks and strengths posed to them will provide the basis for shared understanding, analysis, decision-making and plans about the children and their family.

The social worker on the Gateway team is responsible for drawing all the strands of information together. Health visitors, GP, PSNI, extended family all hold key pieces of information that could protect these children. The Gateway team is responsible for convening the initial case conference. All stakeholders need to contribute.

Similar treads of poor communication, lack of interagency working and inaccurate recording, has consistently reappeared throughout Serious Case Reviews. In 1973 Maria Colwell aged 7 was beaten to death by her stepfather. In 2007 Arthur Mc Enhill set fire to his home killing his whole family, 7 in total and the same year 17month old Peter Connolly died after suffering horrific abuse. Domestic violence was a key feature in all of these tragedies.

Pemberton, (2010, p17) advises,

“Patterns in social history and behaviour can be detected and something, which may appear insignificant in isolation, can be identified as a key warning sign in context”

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